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Tonsillectomy by Diode Laser Versus Cold Steel Dissection Method in Children, Basra, South of Iraq
Rabeea Jabbar Atiyah1* and Hussam Haider Salman2
1ENT Head and Neck surgeon, Al-Habobi Teaching Hospital, Naseriyah, Iraq
2RFRCS, DLO, Iraq
Submission: January 22, 2020; Published: January 28, 2020
*Corresponding author: Rabeea Jabbar Atiyah, M B Ch B, CABMS, ENT Head and Neck surgeon Al-Habobi Teaching Hospital, Naseriyah, Iraq
How to cite this article: Rabeea J A, Hussam H S. Tonsillectomy by Diode Laser Versus Cold Steel Dissection Method in Children, Basra, South of Iraq Glob J Oto, 2020; 21(4): 556067. DOI: 10.19080/GJO.2019.20.556067
Background: Tonsillectomy continues to be a commonly performed operation by the otolaryngologist, although many different methods for tonsillectomy were developed.
Aim of study: To compare between tonsillectomy by diode laser and cold steel dissection regarding the operative time, post-operative pain and post-operative bleeding.
Method: The study included fifty tonsillectomies were performed in the ENT department of Basra General Hospital from February to December 2008. All patients were diagnosed as having chronic or recurrent tonsillitis. Any patient with acute infection or craniofacial anomalies was excluded from the study. The right tonsil dissected by diode laser whiles the left one by cold steel dissection. The average time of surgery was calculated and the post-operative pain at the night of surgery and two weeks later was noticed. data analysis was done by SPSS 11.0
Results: The goblet cells in the group AOM after one week was as dense as those in the control group. There was no difference between the groups in subepithelial edema, the number of eosinophils, subepithelial vasodilatation, intraepithelial gland formation and, subepithelial gland formation (p>0.05). The gland volume and the goblet cells density were extended to peak two weeks after the inoculation since there was primarily a volume increase in the components of the mucous gland. There was a significant increase in the volume of the gland layer within at least 12 weeks after the inoculation of the bacterial middle ear, primarily since there was an increase in a volume of the components of the mucous gland. Although there was a decrease in the volume 12 weeks after acute infection, it was completely normalized after 24 weeks.
Conclusion: The diode laser significantly reduced the operative time but increased post-operative pain. There was no significant difference in the incidence of post-operative bleeding by the two methods.
Tonsils are a part of the Waldayers ring, which is an aggregation of lymphoid tissue located in the nasopharynx and oropharynx at the entrance of the aerodigestive tract. It has an important role in children for its function in immunology and defense mechanism. Antibody secretion, and IgA production, plays a role in mucosal defense mechanism. In the early 20th century, tonsillectomy was the most popular operative procedure for treating various respiratory and systemic diseases . There have been many different studies of methods of tonsils removal and hemostasis.
Probably the two most common techniques are dissection with cold instruments and electrosurgery. However, the dissection technique has remained the standard procedure for tonsillectomy for many years till now . In the last years laser come in advance as a new method of tonsillectomy regarding its advantages to reduce operative time, post-operative pain and bleeding. In our study we used Diode laser to assist in tonsillectomy procedure and the intraoperative and postoperative outcomes is compared to the conventional dissection of tonsillectomy.
Laser is acronym for light amplification by stimulated emission of radiation, surgical lasers are devices that amplify light and create coherent light beams ranging from the infrared to the ultraviolet parts of the spectrum Einstein postulated the theoretical foundation of laser action, stimulated emission of radiation, in 1917. In his classic journal article, “Zur Quantem Theorie der Strahlung” [i.e., “The Quantum Theory of Radiation”], he discussed the interaction of atoms, ions, and molecules with electromagnetic radiation.
He specifically addressed absorption and spontaneous emission of energy and proposed a third process of interaction: stimulated emission. Einstein postulated that the spontaneous emission of electromagnetic radiation from an atomic transition
has an enhanced rate in the presence of similar electromagnetic
radiation. This “negative absorption” is the basis of laser energy.
Many attempts were made in the following years to produce
stimulated emission of electromagnetic energy, but it was not
until 1954 that this was successfully accomplished [4,5].
The reaction of laser energy with living tissue can be photo
ablative, photochemical, photomechanical or photo thermal. Most
lasers react with a combination of all these mechanisms although
for a specific wavelength and delivery system one form of tissue
reaction may predominant.
Across sectional study included fifty tonsillectomies were
performed in the ENT department of Basra General Hospital
during period from February to December 2008. All patients
were diagnosed as having chronic or recurrent tonsillitis by the
usual method of history taken and physical examinations. Any
patient with acute infection, craniofacial anomalies or contra
indications for anesthesia was excluded from the study. The
investigations included Hb% and GUE there was no need for
farther investigations. Parents were told about the study nature of
the procedure and their agreement was taken. The operation done
under general anesthesia right tonsils were removed by diode
laser and the left tonsils by standard steel dissection method.
Patients were not told which tonsil was removed by laser.
Time needed for removal of each tonsil was calculated.
Patients were asked at the night of surgery and two weeks later
about the severity of pain whether more on the right or left sides
of the throat and their responses were recorded. Post-operative
bleeding both primary and secondary were looked for and
the results recorded. All data were entered into a database by
independent statistics personnel. Data were analyzed using the
statistical package for the social sciences version 11.0 software
(SPSS 11.0). The chi-square test and T- test were used to study
associations between variables. the levels of significance were
considered when equal or less than 0.05.
A total of 50 patients were done for them tonsillectomy, by
two surgical method one for right side and other for left side ,
with mean age was 6.36 ± 2.45 year. male patient was 31 while
female was 31, as in figure 1. The mean time calculated for laser
tonsillectomy was 4 minutes while by dissection method was 6.5
minutes, there is a statistically significant difference for the time
consumed by the two methods [p value 0.01] as shown in table 1.
The study reveal that on the evening of surgery about 84% of
the patients identified the throat in which the tonsil was removed
by Diode laser [the right side] as being the most painful, while
10%of the patients identified the throat in which the throat
was removed by dissection method as being most painful, with
statistically significant when p value 0.001 as shown in table 2.
After two weeks following surgery the study was found that
81.5% identified the laser side as most painful side, 10.5% of the
patients identified the side of dissection method more painful, A
statistically significant[p value 0.001] number of patients chose
the laser side as the most painful side two weeks after surgery as
shown in table 3.
In general, the study revealed that pain after tonsillectomy
whether at evening or 2 week later from operation was more
than 80% by laser and 10% by dissection and about 2% was not
assessed as shown in figure 2. In all patients under the study no
post-operative bleeding was occurred so there is no difference
between the two methods regarding the incidence of post
Tonsillectomy continues to be a commonly performed
operation by the otolaryngologist , although many different
methods for tonsillectomy were developed. There are still
controversies over what is the optimal technique for tonsillectomy
with the lowest morbidity rates. various techniques have been
developed to improve post-operative morbidity & many studies
have been performed to compare the new procedure with the
conventional methods [7-9].
The first clinical experience with laser tonsillectomy was
reported in 1972 but it is only recently that the use of laser has
been widespread . Many different types of lasers were used
for tonsillectomy each has its unique physical properties KTP,
ND YAG, CO2 in addition to diode laser. Diode laser has similar
physical prosperities to Nd-yag laser but is superior to Nd yag
laser because of less heat effect to collateral structures . The
cutting or vaporizing action of diode laser is achieved by a (red
hot cautery effect), this allow very delicate cutting and destruction
of tissue with very little lateral damage and seems that it is very
useful for tonsillectomy .
The diode laser emits laser light at a wavelength of 810nm14
this means that good deep coagulation of up to 1 cm depth of
tissue can be achieved . The use of small fibers in contact
mode in diode laser makes the dissection very gentle and is likely
that this will lead to reduction of post-operative morbidity .
The operative time needed for tonsillectomy by diode laser is
significantly reduced in comparison with dissection method in
our study, which goes with the results of Saito et al. , and Auf
et al. . Who compared KTP laser tonsillectomy with dissection
method, although these results are against the findings of both
Strunk et al. ? And Kothari et al. . who also used KTP laser
in comparison with dissection tonsillectomy and this probably
due to increased laser set up time and malfunction which is not
a problem in diode laser because diode laser machine is small compact, portable, efficient, relatively quiet, and very simple
to use, it has a stable power output and expected long life, no
instillation cost and virtually maintenance free .
Post-operative pain at the night of surgery was more in diode
laser side in comparison with the dissection side [P< 0.05], which
is against the result of Saito et al. , Auf et al. , and Aos et
al. . This is probably due to hot cautery effect of Diode laser
which lead to more post-operative pain in comparison with cold
dissection while other types of lasers have a sealing action on the
fine peripheral nerve endings that result in a lowering of subjective
pain post operatively [20,21,22]. Two weeks later post-operative
pain in diode laser side was still more than the dissection side
[P< 0.05], which is the same result of Saito et al. , Kothari et
al. , Auf et al. , and Aos et al. . This probably due to
2ndry opportunistic infection, which is more in laser side, such
an infection might be greater than the infection in dissection side
where there is no layer of thermal necrosis by laser .
In our study no post-operative bleeding occurred whether
primary or 2ndary so there was no difference of post-operative
bleeding between the two methods which goes with result of
Shrunk et al. , D Eredita et al. , and Saito et al.  but is
against the results of Kothari et al. , and Auf et al. . where
there was more post-operative bleeding with laser than dissection
method and this probably is related to surgeons experience in
using the laser & to the type of laser used.
We conclude that there is significant decrease in operative
time with diode laser but there is more post-operative pain with
no difference in both dissection and diode laser tonsillectomy
regarding incidence of post-operative bleeding. We found the main
advantage of diode laser tonsillectomy is to decrease operative
time which is cost effective and important especially in children
patients with poor general health.
Carruth J A S (1982) Resection of tongue with laser. Journal of otolaryngology 96: 529-543.
AL rubeai T M (1997) Co2 laser tonsillectomy: A comparison with standard technique. A thesis submitted to the scientific council of otolaryngology in partial fulfillment for the degree of fellowship of Iraqi commission for medical specialty.