Summer 2005

Kinder, Gentler Tonsillectomy

A new procedure is reducing recovery time in half on tonsillectomies, still one of the most common surgeries in pediatric practice. The new method uses radiofrequency energy to energize saline particles that gradually break down the tonsils and adenoids. During electrosurgery, the current treatment mainstay, heat is generated to burn through the tissue, leaving more traumatized tissue behind. The new technique, called Coblation, which was pioneered in orthopedics more than a decade ago, does not generate heat.

UCSF pediatric otolaryngologist Kristina Rosbe is a leading practitioner of tonsillectomy. "Coblation has been shown in controlled clinical trials to reduce pain, and it allows patients to resume their normal lives more quickly," Rosbe says. The low complication rates — rare cases of dehydration or bleeding several days postsurgery — are comparable to rates obtained with more traditional techniques.

"I used to counsel children and parents that they should expect it to take two weeks for life to return to normal: no pain, normal diet, regular activities. This technique cuts that recovery period in half," Rosbe says.

She has performed dozens of tonsillectomies using Coblation — removing adenoids as well as tonsils — and she now uses it for about half of the tonsillectomies she performs, including all outpatient tonsillectomies. Coblation does not significantly change the time required to complete surgery; the average patient is in the operating room for about an hour for complete removal of tonsils and adenoids. Because of the suggested benefit in reduced recovery times for patients, all otolaryngology residents at UCSF are learning the procedure, along with standard heat-ablation techniques, as part of their specialty training.

The availability of a technique that reduces postoperative pain comes at a good time — tonsillectomies are on the rise. Tonsils and adenoids that are too big are increasingly being recognized as a significant cause of sleep disturbances in children; hence the benefits of tonsillectomy in relieving sleep loss. In fact, research indicates that children with sleep disturbances who receive tonsillectomies rest more easily, and that sleeping better after tonsillectomy often leads to improved attention and learning in school. Difficult breathing, caused by enlarged tonsils, which results in poor-quality sleep, is now the most common health issue leading to tonsillectomy. The second most common reason for recommending that children be evaluated for tonsillectomy is recurrent tonsillitis due to strep-like infections.

Pediatricians generally are accurate when they suspect tonsillectomy would relieve symptoms and benefit a child, Rosbe says, but breathing difficulties due to enlarged tonsils and adenoids can sometimes be missed. "This new data coming out on snoring, sleep disturbance and attention span is interesting, but it's still too early to know how this data should affect our practices," Rosbe adds. "More long-term results in more patients are needed to support increasing tonsillectomy rates for patients with sleep disturbance without a true diagnosis of obstructive sleep apnea."

There was a backlash against performing tonsillectomies after the unnecessary, wholesale tonsil removal that predominated in medical practice during the 1940s and 1950s. But today's climbing tonsillectomy rates generally reflect the procedure's increasingly valuable role in treating nighttime breathing difficulties, according to Rosbe.

All children should be screened for snoring, Rosbe notes. If a child appears to be having breathing difficulties at night, it may be due to other factors such as allergies or, more rarely, central sleep apnea. If physicians and families want a more thorough evaluation of the cause of a child's sleep disturbance, UCSF offers sleep studies through the pediatric sleep lab. Obtaining X-rays to check the size of the adenoids, which cannot easily be visually inspected, may be useful when it is uncertain whether the tonsils are enlarged. If these causes are ruled out and if tonsils are enlarged, tonsillectomy may solve the problem.

For more information, contact Dr. Rosbe at (415) 353-2757.

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