Intracapsular Tonsillectomy Cuts Bleeding and Pain

WILMINGTON, Del., Sept. 17 -- Tonsillectomy that leaves a layer of tissue covering the throat muscles may cause fewer complications than traditional tonsillectomy, but a small percentage of patients may need to go back to surgery to finish the job.

Bleeding more than 24 hours after surgery was about three times less common (P<0.001) among patients who'd undergone the intracapsular procedure than among those who'd had traditional electrodissection surgery, according to a retrospective study published in the September issue of Archives of Otolaryngology-Head & Neck Surgery.

Severe pain was also significantly less common (P=0.002), but 0.64% of children who underwent intracapsular tonsillectomy required revision surgery whereas none did with the traditional procedure, said Richard Schmidt, M.D., of the Alfred I. duPont Hospital for Children here, and colleagues.

Intracapsular tonsillectomy uses a microdebrider to remove at least 90% of the tonsil while sparing the capsule covering the underlying pharyngeal constrictor muscle.

This method is one of many modifications to the basic tonsillectomy techniques that have been promoted over the years for what is one of the most common of all surgeries performed in the United States, they said.

"When first introduced, all of these techniques were touted to cause less pain or have a lower incidence of bleeding than traditional sharp dissection," they wrote. "In most cases, as the techniques became more widely used, these promises were not fulfilled."

To see if intracapsular tonsillectomy would buck this trend, the researchers reviewed outcomes for 2,944 consecutive patients (all children) who underwent tonsillectomy or adenotonsillectomy at their institution from 2002 through 2005.

This included 1,731 intracapsular procedures and 1,212 traditional procedures, of which the vast majority was done using monopolar electrodissection with suction cautery for additional bleeding control.

Adenotonsillar hypertrophy was the predominant indication for surgery in both groups. But it accounted for a different proportion of procedure in the intracapsular and traditional tonsillectomy groups (79.0% versus 56.0%, respectively) as did infection (15.4% versus 32.3%).

Follow-up averaged 20.5 months overall, but was longer in the traditional tonsillectomy group (24 months versus 18).

Only three cases of primary hemorrhage within 24 hours of surgery occurred, with no difference between groups (0.1% for both, P=0.57).

However, secondary hemorrhages more than 24 hours after surgery were significantly less common in the intracapsular tonsillectomy group both overall (19 versus 41, 1.1% versus 3.4%, P<0.001) and for those that had to be treated in the operating room (0.5% versus 2.1%, P<0.001).

Visits to the emergency department or readmission to the hospital for pain with or without dehydration -- a retrospective measure of severe pain -- were likewise lower with the intracapsular procedure (57 versus 67, 3.0% versus 5.4%, P=0.002).

The same patterns were seen in each subgroup of patients by surgical indication.

Among those with hypertrophy, the findings for intracapsular versus traditional tonsillectomy were:

• Fewer secondary hemorrhages (1.1% versus 2.4%, P=0.03).
• Fewer secondary hemorrhages that required treatment in the operating room (0.4% versus 1.5%, P=0.01).
• A nonsignificant tendency toward fewer visits to the emergency department for pain or dehydration (3.4% versus 5.2%, P=0.07).

Among those with an indication of recurrent infection, the findings for intracapsular versus traditional tonsillectomy were:

• Fewer secondary bleeding complications (1.5% versus 5.3%, P=0.01).
• A nonsignficant tendency toward fewer secondary hemorrhages that required treatment in the operating room (1.1% versus 3.1%, P=0.18).
• Fewer visits to the emergency department for pain or dehydration (1.5% versus 5.1%, P=0.02).

For the small group of children who had both recurrent infections and hypertrophy, the trends were consistent with the other groups, although not significant.

"The ideal tonsillectomy would have minimal or no risks and be completely effective," Dr. Schmidt and colleagues wrote.

While intracapsular tonsillectomy better meets that standard for risks than traditional tonsillectomy, "the procedure is not always effective," the researchers noted.

The rate of revision surgery to complete the tonsillectomy was 0.64% in the intracapsular surgery group versus 0.0% in the traditional surgery group (11 patients versus none).

Nevertheless, overall, patients treated with intracapsular tonsillectomy were no more likely to require a return trip to the operating room for any reason, including revision tonsillectomy, and actually tended to return less frequently than those treated with traditional tonsillectomy (1.2% versus 2.1%, P=0.07).

The study also had its flaws, particularly the retrospective design, so that one cannot assume that the two groups were equal, the researchers noted.

The longer follow-up in the traditional tonsillectomy group may also have had an effect on the number of patients who required a revision tonsillectomy, but likely would not have had an impact on the number of acute complications, they added.