TONSILLAR RADIO-ABLATION

Scientific Paper- This an exert from published article: Modified for better understanding

Author: Dr. Mansoor Madani

Introduction:
Although there has been a significant drop in number of tonsillectomies performed annually in children, there are millions of adults that suffer from chronic irritation of the tonsils.  Enlarged tonsils are one of the contributing factors in obstructive sleep apnea. Many complications have been reported with traditional tonsillectomies, including infection, bleeding, dehydration, angular cheilitis, Dysgeusia, pulmonary edema and loss of time from work or school.  

Background of tonsillectomy:

There have been varieties of methods advocated to resect the tonsils including the use of guillotine, electrocautery, laser and bipolar scissor.  In early 1999, the author introduced tonsillar radio-ablation.  Hundreds of patients were treated with a similar procedure for palatal radio-ablation.  Patients were seen for the treatment of enlarged tonsils because of chronic inflammation, (multiple) tonsillitis, multiple Strep throat infections requiring frequent antibiotic treatment, obstruction of the airway, and snoring problems. Other considerations were chronic tonsillar hyperplasia, with tonsillar crypt causing further accumulation of food and bacteria leading to infection and halitosis.  It must be emphasized to patients that RF procedures primarily reduce the tonsillar size and are not designed to remove the tonsils.  The debulking process may require repeat sessions later for further reduction of the tonsils.

Tonsillar radioablation (Tonsillar channeling procedure)

There are certain precautions that are recommended with this procedure to avoid complications.  Starting two days prior to the surgery, patients are placed on antibiotic prophylaxis, or IV administration of antibiotics one hour prior to surgery for a non-infected and non-inflamed tonsil. Chlorohexidine (Peridex®) mouth rinse is given several days prior to surgery and patients are asked to continue to use it twice daily for at least two months post-operatively.  Assurance is made to identify and manage any pre-existing infection, fever and sore throat. 

The patient is placed in the supine position. Chlorohexidine (Peridex®) mouth rinse is given to the patient to keep in the mouth, gargle and rinse for one minute.  Two-3 ml of Marcaine 0.5% with 1:200,000 Epinephrine is injected into the base of the tonsil starting in the lateral part of the soft palate and extending to the area of the lateral wall of the pharynx (tonsillar bed).   A plastic double-cheek retractor is placed on the inside of the cheek to give the best visualization and also to protect the patient’s lips.

The Coblation® unit is set to 6 and the Coblation® Reflex wand 55 is used to deliver the appropriate energy.  A conductive saline gel is used and applied to the entire uninsulated portion of the probe and is placed on the most prominent surface of the tonsil (Figure 7). The foot pedal is used for a short period of time to activate the unit and to insert the probe into the tonsil.  Superficial heating of the tonsillar mucosa must be avoided to prevent superficial erosion.  This procedure is a submucosal procedure and does not include resection of the tonsils in most cases.  Once the un-insulated probe is completely inserted in a horizontal direction, the energy is applied for approximately 10-15 seconds. The same procedure is repeated four to six additional times on that side.  This step is repeated on the other side.

TONSILLAR RADIO-ABLATION POST-OP CARE

Patients are carefully monitored and evaluated for need of additional procedures.  The patients are advised that the healing process takes up to three months following surgery and additional treatments may be necessary. These procedures do not remove the tonsils in their entirety nor do they cure sleep apnea.  They will not necessarily prevent a common cold or future Strep infections.  The patients are discharged after assurances are made that there is no bleeding and the detailed explanation of the postoperative instructions are given.  

Generally, a prophylactic antibiotic, such as Cipro® (Ciprofloxacin hydrochloride, Bayer Corp, West Haven CT), Keflex® (Cephalexin, Dista Products, Co., Indianapolis, IN) or Cleocin® (clindamycin hydrochloride, Pharmacia & Upjohn, Peapack, NJ), is given to the patient prior to the surgery, and patients must continue to take it for a period of 10 days after the procedure.  Additionally, they are asked to use a Chlorohexidine mouth rinse twice daily for a period of two months following surgery and a regular mouth wash as often as possible.  Pain medication is generally limited to an over-the-counter pain reliever.  A sensation of tightness in the back of the throat is normal for the first week after the procedure.  Patients are advised to return in one week unless there was a need to return earlier and weekly then after. 

TONSILLAR RADIO-ABLATION RESULTS
One hundred eighty-seven patients (please not these patients were amongst our earliest cases treated the total number of cases performed at present time are much higher) , with age range of 13-56 were treated in an office setting with the Coblation® channeling to reduce tonsillar bulk.  The group was comprised of 124 (66%) male and 63 (34%) female patients.  Thirty-nine percent of patients were treated because of frequent tonsillar infections and 61% were treated to alleviate the symptoms of obstructive sleep apnea.  Patients were followed up from three months up to two years with an average of 15 months. There was no bleeding during or after the procedures.  Two patients developed a recurrence of their tonsillar infection up to 6 months after surgery.  The discomforts were minimal and, if needed, patients were advised to take over-the-counter pain relievers.  All procedures were done in an office setting with average duration of procedures under 30 minutes.  All patients treated reported no voice changes or fluid reflux.  The day after the procedures, 100% of patients returned to work or school. 

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