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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 211-218

Comparative study between radiofrequency coblation and traditional adenoidectomy


Departments of Otorhinolaryngology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission06-Apr-2018
Date of Acceptance08-Oct-2018
Date of Web Publication27-Feb-2019

Correspondence Address:
Mohammed A El Sharkawy
5 Mohammed Imam Street, Menyat El Sereg, El Sahel, Cairo, 11672
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_20_18

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  Abstract 

Background Adenoid hypertrophy is known to be the most common cause of nasal obstruction in children; thus, adenoidectomy with or without tonsillectomy is one of the most commonly performed surgical procedures in the pediatric population. The widely used conventional curette adenoidectomy was first described. Dissatisfaction with this technique led to the use of other methods, including powered-shaver adenoidectomy, bipolar electrocautery, coblation, and LASER.
Aim This study aimed to compare the endoscopic-assisted coblation adenoidectomy to conventional adenoidectomy (by cold instruments) in terms of safety, efficacy, results, and complications.
Patients and methods Eighty patients were diagnosed depending on history, clinical examination, and radiology. The patients were operated on by either conventional or coblation adenoidectomy and divided into two groups: the patients in group A underwent conventional adenoidectomy, whereas the patients in group B underwent coblation adenoidectomy. The intraoperative parameters studied were operative time, intraoperative bleeding, and completeness of removal of adenoid. Postoperative parameters included assessment of postoperative pain, resolution time, and complications.
Results It was found that although coblation has a longer operative time, it is a safe and effective alternative to curette adenoidectomy, it is more complete and accurate, there is less intraoperative blood loss, less postoperative pain, and fast resolution time, and fewer complications.
Conclusion Coblation adenoidectomy proved to be safe and effective; however, reducing the cost is mandatory before considering it as the modality of choice for adenoidectomy.

Keywords: adenoidectomy, conventional, coblation


How to cite this article:
Abd El Rahman AA, El Shehaly AA, Dawood YM, El Sharkawy MA, Shalaby IT. Comparative study between radiofrequency coblation and traditional adenoidectomy. Al-Azhar Assiut Med J 2018;16:211-8

How to cite this URL:
Abd El Rahman AA, El Shehaly AA, Dawood YM, El Sharkawy MA, Shalaby IT. Comparative study between radiofrequency coblation and traditional adenoidectomy. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 6];16:211-8. Available from: http://www.azmj.eg.net/text.asp?2018/16/2/211/253082


  Introduction Top


The ideal adenoidectomy procedure should lead to safe removal of the adenoids with less operative time, blood loss, postoperative morbidity, and/or recurrence [1].

In the last few years, different adenoidectomy techniques have been proposed to reduce morbidity and surgical risk (e.g. microdebrider, bipolar coagulation, coblation) [2].

Coblation has been proven to be a popular method for adenoidectomy. Several authors have claimed significant advantages over other methods, suggesting that, by operating at lower temperatures than that of diathermy, coblation may result in less surrounding tissue damage, reduce postoperative pain and bleeding, and promote healing [3].


  Aim Top


This study aimed to compare an endoscopic surgical technique using (coblator) for adenoidectomy to traditional cold curettage in terms of safety, efficacy, results, and complications.


  Patients and methods Top


A prospective, randomized study was carried out on 40 children (21 males and 19 females ranging from 3 to 10 years old) attending the outpatient clinic of Al-Azhar University Hospital (Al Hussein) during the period from December 2016 to June 2017, selected randomly, with symptoms and signs suggestive of adenoid hypertrophy obstructing the nasopharynx on the basis of the following criteria:

Inclusion criteria were as follows:
  1. Obstructive symptoms such as long-lasting nocturnal snoring, sleep apnea, and open mouth breathing, bilateral nasal obstruction, and/or bilateral nasal discharge.
  2. Adenoid hypertrophy as the only cause of nasal obstruction.
  3. Radiography evidence of adenoid hypertrophy encroaching on the airway column.
  4. Age range from 3 to 10 years.


Exclusion criteria were as follows:
  1. Presence of chronic diseases such as chronic heart diseases, chronic liver diseases, chronic renal diseases, and diabetes mellitus.
  2. Other causes of nasal obstruction such as acute rhinitis, allergic rhinitis, septal deviation, or anatomical deformities (Choanal atresia).
  3. Cases with submucous cleft palate and cases with a previous history of cleft palate repair.
  4. Patients with bleeding or coagulation defects.
  5. Patients younger than 3 years or older than 10 years of age.
  6. Recurrent cases.


Preoperative assessment included the following:
  1. Assessment of history and clinical examination.
  2. Radiological examination by radiography nasopharynx (lateral view) ([Figure 1]).
    Figure 1 Radiography of a case from group B.

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  3. Routine preoperative laboratory investigations, for example, CBC, PTT, PT, PC, INR, etc.


Groups

Forty patients of both sexes were included in this study; all had adenoid hypertrophy (with or without chronic tonsillitis). Patients were divided into two groups. The cases were divided randomly into two equal groups (curette adenoidectomy group and coblator adenoidectomy group); each group included 20 patients. All surgeons who participated in the study had the same surgical qualifications and had almost the same level of surgical training.

Group A: transoral curette adenoidectomy

Twenty patients ranging in age between 3 and 10 years, with a mean age of 6.25±2.47 years, underwent traditional transoral curette adenoidectomy in which the adenoids were removed using variable-sized adenoid curettes. Complete removal was then confirmed by digital palpation and mirror visualization or by a transoral 70 degrees endoscope. After complete hemostasis was carried out, nasopharyngeal packing was removed.

Group B: coblation adenoidectomy

Twenty patients ranging in age between 3 and 10 years, with a mean age of 5.85±1.98 years, underwent coblation adenoidectomy. For coblation adenoidectomy, a coblator Evac 70 Xtra device (ArthroCare, Sunnyvale, California) on a power setting of nine for coblation and five for coagulation was used. Under general anesthesia, coblation was performed using nasal endoscopy (0 degrees endoscope) ([Figure 2],[Figure 3],[Figure 4]).
Figure 2 Preoperative adenoid tissue.

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Figure 3 Adenoid wand ablating adenoid tissue.

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Figure 4 Postcoblation adenoid bed.

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Parameters of working

The intraoperative parameters studied were operative time, intraoperative bleeding, and completeness of adenoid removal. Postoperative parameters included assessment of postoperative pain (using Wong–Baker faces rating scale) ([Figure 5]), postoperative complications (e.g. hemorrhage), and resolution time.
Figure 5 Wong–Baker FACES Pain Rating scale (after the Wong–Baker foundation).

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Statistical analysis

Data were analyzed using statistical program for social science (IBM , Manhattan, New York city, USA), version 20.0. Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage.

The following tests were performed:

(1) Independent samples t test of significance was used to compare between two means.

(2) χ2 test of significance was used to compare proportions between two qualitative parameters.


  Results Top


Forty patients of both sexes with adenoid hypertrophy (with or without tonsillitis) were included in this study. The patients were divided into two groups.

Group A: 20 patients, 11 males and nine females, ranging in age between 3 and 10 years, with a mean age of 6.25±2.47 years, underwent a traditional curette adenoidectomy. Nine of them underwent adenotonsillectomy.

Group B: 20 patients, 10 males and 10 females, ranging in age between 3 and 10 years, with a mean age of 5.85±1.98 years, underwent transoral video endoscopic adenoidectomy with a coblator. Eight of them underwent tonsillectomy ([Table 1]).
Table 1 Sex and age distributions among all groups

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Comparisons between the two groups were made in terms of the following factors.

Operative time

The operation times for patients in group A varied from 5 to 30 min, with a mean of 10.22 min, whereas in group B, it ranged from 13 to 35 min, with a mean of 22.4 min ([Figure 6] and [Table 2]).
Figure 6 Comparison between the mean operative time for both groups.

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Table 2 Comparison between the two groups in the operative time

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Amount of blood loss

The mean intraoperative blood loss was 61.5 ml (range, 20–370 ml) in group A, whereas in group B, it ranged from 5 to 20 ml, with a mean of 8.8 ml ([Figure 7]).
Figure 7 Comparison between postoperative bleeding between both groups.

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The difference in intraoperative blood loss was found to be statistically significant ([Table 3]).
Table 3 Comparison between the two groups in intraoperative bleeding

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Presence of residual lymphoid tissue

Postoperative endoscopy to look for residual adenoid tissue showed that resection was invariably complete by coblation in group B. In contrast, in four patients (20%) in group A, there were remnants of adenoid tissue ([Figure 8] and [Table 4]).
Figure 8 Percentage of patients with residual adenoid.

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Table 4 Description of residual adenoid tissue in group A only (N=20)

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Postoperative bleeding

Two cases in group A developed primary hemorrhage, whereas none of the cases of group B developed postoperative uncontrolled bleeding ([Figure 9]).
Figure 9 Comparison of postoperative bleeding between both groups.

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Postoperative pain scores

Group A pain score:
  1. Five patients chose image 2.
  2. Seven patients chose image 4.
  3. Two patients chose image 8.
  4. Six patients chose image 6.


Group B pain score:
  1. One patient chose image 0.
  2. Four patients chose image 3.
  3. Thirteen patients chose image 2.
  4. Two patients chose image 6.


Postoperatively, during the first 24 h, the difference in pain scores was significant between the two groups ([Figure 10] and [Table 5]).
Figure 10 Comparison of the mean operative pain for both groups.

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Table 5 Postoperative pain

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Resolution time

Children in the coblation adenoidectomy group (group B) reported significantly fewer days of reporting pain, analgesic days, liquid diet days, and absence from school days.

In group A, the mean resolution period was 4.8 days, whereas in group B, the mean resolution period was 2.9 days ([Figure 11] and [Table 6],[Table 7],[Table 8]).
Figure 11 Comparison of the mean resolution periods of the two groups.

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Table 6 Early resolution after surgery

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Table 7 Comparison between groups according to complications

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Table 8 Comparison between two methods

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  Discussion Top


In this study, the operative time for coblation adenoidectomy was more than that of conventional adenoidectomy and blood loss was lower in coblation adenoidectomy than that in conventional adenoidectomy. The differences in time taken and blood loss in the two used procedures were found to be significant.

This study showed that the mean operative time of the procedure was 10.55±7.23 min for conventional adenoidectomy, whereas it was 22.30±6.50 min for coblation adenoidectomy, and the mean blood loss was 61.5 ml (range, 20–370 ml) for conventional adenoidectomy, whereas it was 8.8 ml (range, 5–20 ml) for coblation adenoidectomy.

This study found that postoperative pain was less and return to normal diet and activity occurred earlier with the coblation technique than the traditional one.

Also, this study found that there was no residual tissue after coblation adenoidectomy. In contrast to this, 20% of conventional adenoidectomy residual adenoid tissue was left and removed before recovery from anesthesia.

This study also found that two cases in group A developed primary hemorrhage and no cases in group B developed any complication.

These findings are comparable to those of previous studies by Di Rienzo Businco et al. [4], who proved that the main advantages observed in coblation adenoidectomy, compared with the cold curettage technique, were as follows: (a) lack of bleeding; (b) provides a direct endoscopic view of the adenoid; (c) the ability to reach all the areas of the nasopharynx up to the Eustachian tube opening; (d) lower risk of residual adenoid tissue after coblation; (e) fewer complications; (f) suitable for patients of all ages, although the decrease in pain intensity and duration is significant in pediatric patients; and (g) a reduction in the use of postoperative drugs and loss of working days for parents because of faster postsurgical healing. Compared with traditional cold curettage, endoscopic coblation adenoidectomy also enables selective and precise ablation of the adenoid tissue. Intraoperative and postoperative bleeding was not observed and adjacent structures such as the tubes, nasal, and pharyngeal mucosa were preserved carefully.

Also, as reported by others, Timms et al. [5], coblation adenoidectomy is associated with less postoperative neck pain than curette/cautery adenoidectomy. Respiratory outcomes after endoscopic coblator adenoidectomy, as we have observed previously after long-term follow-up, are within the normal range and stable, with no risk of recurrence (according to our histological results) or persistence of adenoid tissue. Data from the nasal decongestion test indicate the persistence of adenoid tissue as the main reason for high nasal resistance values in the cold curettage group of patients.

Also, this study is in agreement with the Ozkiriş et al. [6] study, in which traditional cold curettage was compared to endoscopic-assisted coblation adenoidectomy, which enabled more selective and precise ablation of the adenoid tissue. Intraoperative bleeding was observed to be minimal and adjacent structures such as the nasal and pharyngeal mucosa were carefully preserved. The operation duration was lower in the curettage group compared with the coblation group. Despite longer operation durations because of endoscopic control of the nasopharynx, more accurate removal of hypertrophied adenoid tissue under direct vision was performed with coblation adenoidectomy.

In 2007, Shapiro and Bhattacharyya [1] found that coblation adenoidectomy offered significant intraoperative advantages over the conventional technique. In particular, coblation led to significantly faster operative times in the performance of adenotonsillectomy. In addition, despite this increase in speed, intraoperative blood loss was also statistically significantly lower with coblation than with the cold dissection technique. Thus, similar to electrosurgical techniques, coblation enhances operator control and surgical efficiency with adenotonsillectomy. The majority of coblation patients had intraoperative blood loss of less than 10 ml, and the majority of conventional adenoidectomy patients had an intraoperative blood loss of more than 10 ml. Although it could be argued that the clinical significance of this difference is negligible, resulting in a nearly ‘bloodless’ surgery, without a significantly increased risk of postoperative hemorrhage, it is oftentimes an attractive option for parents whose children are undergoing surgery, which is in agreement with the result of this study.

In a randomized-controlled trial, Temple and Timms [7] showed that there was significantly less pain (P<0.0001) and narcotic use following coblation. There was also a faster return to a normal diet (2.4 vs. 7.6 days on an average). Similar results were obtained by Mitic et al. [8]. Both of these studies are in agreement with the results of this study.

Also, Timms et al. [5] reported coblation to be superior to traditional methods of adenoidectomy.


  Conclusion Top


Despite the longer operation time of endoscopic-assisted coblation adenoidectomy, it enables precise, complete, and safe removal of adenoid tissue. Also, there is less intraoperative bleeding, with better control of hemorrhage, and patients have less postoperative pain and faster healing.

The main and only disadvantage of the coblator is its high cost. Therefore, it is important to reduce the cost before considering it as the modality of choice for this commonly performed procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shapiro NL, Bhattacharyya N. Cold dissection versus coblation assisted adenotonsillectomy in children. Laryngoscope 2007; 117:406–410.  Back to cited text no. 1
    
2.
Songu M, Altay C, Adibelli ZH, Adibelli H. Endoscopic-assisted versus curettage adenoidectomy: a prospective, randomized, double-blind study with objective outcome measures. Laryngoscope 2010; 120:1895–1899.  Back to cited text no. 2
    
3.
Rabbani MZ, Iqbal Z, Zafar MJ. Post-tonsillectomy haemorrhage: is day care surgery safe? J Pak Med Assoc 2010; 60:559–561.  Back to cited text no. 3
    
4.
Di Rienzo Businco L, Angelone AM, Mattei A, Ventura L, Lauriello M. Paediatric adenoidectomy: endoscopic coblation technique compared to cold curettage. Acta Otorhinolaryngol Ital 2012; 32:124–129.  Back to cited text no. 4
    
5.
Timms MS, Ghosh S, Roper A. Adenoidectomy with the coblator: a logical extension of radiofrequency tonsillectomy. J Laryngol Otol 2005; 119:398–399.  Back to cited text no. 5
    
6.
Ozkiriş M, Karaçavuş S, Kapusuz Z, Saydam L. Comparison of two different adenoidectomy techniques with special emphasize on postoperative nasal mucociliary clearance rates: coblation technique vs. cold curettage. Int J Pediatr Otorhinolaryngol 2013; 77:389–393.  Back to cited text no. 6
    
7.
Temple RH, Timms MS. Paediatric coblation tonsillectomy. Int J Pediatr Otorhinolaryngol 2001; 61:195–198.  Back to cited text no. 7
    
8.
Mitic S, Tvinnereim M, Lie E, Saltyte BJ. A pilot randomized controlled trial of coblation tonsillectomy versus dissection tonsillectomy with bipolar diathermy haemostasis. Clin Otolaryngol 2007; 32:261–267.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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