Surgical removal of the tonsils and adenoids (known as a T&A) is one of the most common operations performed on children in the U.S. As noted in the illustration above, tonsils are located on either side of the throat and adenoids are located behind the nose. When these are enlarged they can block flow of air through the nose and the mouth. Additionally recurrent infections can lead to recurrent sore throat (known as recurrent or chronic tonsillitis). Adenoids are located behind the nose and can also cause nasal airflow obstruction and are often removed in conjunction with the tonsils.
As one of the oldest described surgical procedures on record, tonsillectomy was described as early as 1000 B.C. It was popularized in the 1800s as life saving procedure to remove obstruction from severe cases of Diphtheria. Given its history and popularity, the technique for performing the procedure is constantly undergoing refinement from its early days using cold steel scissors or knife and electrocautery to modern days of plasma field dissection.
The major points of concern for tonsillectomy include length of surgery (shorter anesthesia time means less exposure to anesthesia drugs and lower risks of complication), amount of bleeding during surgery, risk of bleeding after surgery and amount of pain after surgery.
The two techniques that I want to compare are cold steel and/or electrocautery technique versus coblation. Cold steel technique essentially involves cutting the tonsils using various sharp cutting instruments, often knife, snares etc. This is often followed by “cauterizing” or burning the bleeding vessels using electrical current (electrocautery). So in fact the “cold” technique is not cold at all and can get as hot as 1200 degree celsius due current that needs to be delivered after tonsils are removed to stop the bleeding. The amount of heat delivered makes a difference. Any heat applied to surrounding muscles and tissues outside of the tonsils can be considered “collateral damage” and will contribute to increased post-operative pain and tougher recovery period.
Coblation on the other hand uses the Coblator wand by Arthrocare(TM), that cuts through tissues by creating a plasma field (created by running current through a continuously flushing salt water medium) while coagulating blood vessels (to stop bleeding) at the same time. Temperature typically range in the 40-65 degree celsius range so collateral tissue damage is often minimal.
Several studies have shown benefits in terms of operating time, bleeding and post-operative pain and recovery from use of coblator (1, 2, 3). Because of this, I almost uniformly use this device for tonsillectomies in children under 12 years of age. In teenagers and adults, larger blood vessels and presence of thick scar tissue from years of infection often necessitates use of stronger currents delivered by electrocautery. Although there is certainly a role for electrocautery and or even cold steel tonsillectomy, I find that coblator is a suitable technology for performing tonsillectomies in younger children that may offer benefits of a faster surgery with lower blood loss and faster post-operative recovery.
Have you or your child had a tonsillectomy experience in recent months or years with a particular technology that you would like to share? Please do so in the comment section below. Note: comments are visible to the public.
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You may have heard about kidney stones or gallbladder stones, but did you know that your saliva leaves behind deposits that can also turn into stones? These stones can form deep within the saliva glands or saliva ducts throughout the mouth — or even within the crevices of the tonsils.
Stones in the saliva glands located in the cheeks or under the jaw can block the flow of saliva. This can result in minor discomfort to severe pain and swelling. In some cases, stones can cause infections severe enough to require hospitalization.
Just like other types of stones that can form in our bodies, there are not many proven methods to prevent salivary gland stones. Staying well hydrated only gets you so far when your body is predisposed to form these stones.
If you are experiencing periodic cheek swelling or swollen glands under the jaw, often occurring during or immediately after eating food, you may have salivary stones. If you have a blockage that has caused an infection, the swelling can become even more painful and persistent and will not clear up without antibiotics.
In the past, we generally diagnosed these stones with imaging studies, such as ultrasound or CT scan. There are cases that are difficult to diagnose with imaging studies, however. Some stones are invisible on x-rays because of their size, and occasionally something other than a stone (such as a scar band inside the mouth) can cause blockage of a saliva duct.
Fortunately a new, minimally invasive technology using ultrathin endoscopes (less than 2mm diameter) called sialoendoscopy now allows us to see directly into the salivary glands to diagnose and even treat various salivary gland disorders. Small stones in the ducts can be seen, grasped and removed using this special endoscope. Dilations and directed medication delivery can also be performed with sialendoscopes.
Despite technological advances, certain stones still cannot be retrieved in a minimally invasive fashion. Large stones located within the depths of the saliva glands generally can’t be taken out and so we must remove the entire gland. Fortunately, there are many salivary glands located throughout the mouth and throat to make up for the loss of a single gland.
Do you have any interesting personal stories about saliva gland stones or their retrieval? Please share in the comment section below. (note: comments are publicly visible)