You are on page 1of 45

Role of Coblation In otolaryngology

1. Coblation the Physics behind it Pages 1 5 2. Coblation an overview Pages 6-11 3. ashi!a"s #osterior cordecto!y $sing coblation %$r e&#erience Pages 12 2' (. Coblation )onsillecto!y o$r e&#erience Pages 21 2* 5. Coblation +ands Pages 3' 3, 6. Coblation adenoidecto!y o$r e&#erience 3- - (3

ISSN: 2250-0359

Volume 4 Issue 1.5 2014

Coblation the physcis behin it


!alasub"amanian #hia$a"a%an Stanley &e ical Colle$e

Int"o uction: #he technolo$y o' usin$ plasma to ablate biolo$ical tissue (as 'i"st esc"ibe by )olos*+o an ,ilb"i e 1. !y thei" pionee"in$ (o"+ in this 'iel they p"o-e that "a io '"e.uency cu""ent coul be passe th"ou$h local "e$ions o' the bo y (ithout ischa"$e ta+in$ place. /a io '"e.uency technolo$y 'o" me ical use 0'o" cuttin$1 coa$ulation an tissue essication2 (as popula"i*e by Cushin$ an !o-ie 2. Cushin$ an eminent neu"osu"$eon 'oun this technolo$y e3cellent 'o" his neu"osu"$ical p"oce u"es. 4i"st use o' this technolo$y insi e the ope"atin$ "oom too+ place on octobe" 1st 1925 at 6ete" !ent !"i$ham 7ospital in !oston1 &assachusetts. It (as 8" Cushin$ (ho "emo-e a t"oublesome int"ac"anial tumo" usin$ this e.uipment. Coblation is non-the"mal -olumet"ic tissue "emo-al th"ou$h molecula" issociation. #his action is mo"e o" less simila" to that o' 93cime" lase"s. #his technolo$y uses the p"inciple that (hen elect"ic cu""ent is passe th"ou$h a con uctin$ 'lui 1 a cha"$e laye" o' pa"ticles +no(n as the plasma is "elease . #hese cha"$e pa"ticles has a ten ency to accele"ate th"ou$h plasma1 an $ains ene"$y to b"ea+ the molecula" bon s (ithin the cells. #his ultimately causes isinte$"ation o' cells molecule by molecule causin$ -olumet"ic "e uction o' tissue. &e ical e''ects o' plasma has spu""e a e-olution o' ne( science :6lasma &e icine;. It is no( e-i ently clea" that 6lasma not only has physical e''ects 0cuttin$ an coa$ulation2 on the tissues but also othe" bene'icial the"apeutic e''ects too. 6lasma not only coa$ulates bloo -essels but also econtaminates su"$ical (oun the"eby 'acilitatin$ bette" (oun healin$. #he"apeutic application o' plasma assumes that plasma ischa"$es a"e i$nite at atmosphe"ic p"essu"e. 6lasma &e icine: #his 'iel o' me icine can be sub i-i e into: 1. 6lasma assiste mo i'ication o' bio"ele-ant su"'aces

2. 6lasma base

econtamination an ste"ili*ation

3. 8i"ect the"apeutic application

6lasma assiste mo i'ication o' bio"ele-ant su"'aces: #his techni.ue is use to optimi*e the bio'unctionality o' implants1 o" to .uali'y polyme" su"'aces 'o" cell cultu"in$ an tissue en$inee"in$. 4o" this pu"pose $ases that o not '"a$ment into polyme"isable inte"me ia"ies upon e3citation shoul be use . ,ases that o not '"a$ment inclu e ai"1 nit"o$en1 a"$on1 o3y$en1 nit"ous o3i e an helium. 93posu"e to such plasma lea s to ne( chemical 'unctionalities. 6lasma base econtamination an ste"ili*ation:

Not all su"$ical inst"uments can be e''ecti-ely ste"ili*e usin$ cu""ently a-ailable technolo$ies. #his is ue to the 'act that plastics cannot be e''ecti-ely be ste"ili*e by con-entional means as it coul $et e$"a e on e3posu"e to steam an heat. 6lasma ischa"$es ha-e been 'oun to be "eally use'ul in this scena"io because o' its lo( tempe"atu"e action. #he natu"e o' plasma actions on bacte"ia e3ten s '"om sublethan to lethal e''ects. Sublethal e''ects cause bacte"iostatic chan$es1 (hile lethal e''ects cause bacte"ioci al chan$es. 8i"ect the"apeutic application: #his is pu"ely su"$ical application both in otola"yn$olo$y an o"thopae ic su"$e"ies. 6lasma is use to ablate tissue (ith minimal blee in$. < b"oa spect"um o' plasma sou"ces e icate 'o" biome ical applications ha-e been e-elope . #hese inclu e: 1. 6lasma nee le 3 2. <tmosphe"ic p"essu"e plasma plume 3. 4loatin$ elect"o e ielect"ic ba""ie" ischa"$e 4. <tmosphe"ic p"essu"e $lo( ischa"$e to"ch 5. 7elium plasma %ets 5. 8ielect"ic ba""ie" ischa"$e =. Nano secon plasma $un

4i$u"e sho(in$ plasma nee le. #he $lo( is col enou$h to be touche

8ielect"ic ba""ie" ischa"$e: #his is the technolo$y use in the"apeutic coblato"s. #his is cha"acte"ise by the p"esence o' atleast one isolatin$ laye" in the ischa"$e $ap 4 .

Ima$e sho(in$ coblato" (an (ith th"ee elect"o es sepa"ate by ce"amic

4o" e''ecti-e use o' this technolo$y 'o" su"$ical p"oce u"es the plasma $ene"ate by the (an > elect"o e shoul be uni'o"m.5 #he uni'o"mity o' plasma can be ensu"e by: 1. Inc"easin$ p"eioni*ation o' the $as thus ensu"in$ $ene"ation o' mo"e a-alanches 2. Sho"tenin$ o' -olta$e "ise time #he"apeutic applications o' plasma: 6lasma t"eatment is +no(n to cause coa$ulation o' la"$e blee in$ a"eas (ithout in ucin$ a itional collate"al tissue nec"osis. ?the" metho s causin$ coa$ulation act the"mally p"o ucin$ a nec"otic *one a"oun the t"eate spot. Non the"mal coa$ulation is cause ue to "elease o' Na an ?7 ions (hich causes "elease o' th"ombin. Coblation technolo$y is (i ely use in the 'iel o' otola"yn$olo$y 'o" pe"'o"min$: 1. #onsillectomy 2. < enoi ectomy 3. @666 4. #on$ue base "e uction 5. #u"binate "e uction 5. Aashima p"oce u"e 'o" bilate"al ab ucto" pa"alysis =. 6apilloma -ocal co" s

/e'e"ences: 1. B. )olos*+o et al.1 Case"s in Su"$e"y: < -ance Cha"acte"i*ation1 #he"apeutics1 an Systems D1 /. /. <n e"son et al.1 9 s. !ellin$ham1 )<: S6I91 20001 -ol. 390=1 pp. 305E315 2. 7. Cushin$ an ). #. !o-ie1 :9lect"osu"$e"y as an ai to the "emo-al o' int"ac"anial tumo"s1; Su"$. ,ynecol. ?bstet.1 -ol. 4=1 pp. =51E=F41 192F. 3. &. Ca"oussi an D. Cu1 G/oom-tempe"atu"e atmosphe"ic p"essu"e plasma plume 'o" biome ical applications1G <pplie 6hysics Cette"s F= 0112 020052. 4. @l"ich Ao$elschat*1 G8ielect"ic-!a""ie" 8ischa"$es: #hei" 7isto"y1 8ischa"$e 6hysics1 an In ust"ial <pplications1G 6lasma Chemist"y an 6lasma 6"ocessin$ 23 0121 1-45 020032

5. !. Hi1 /en C.1 )an$ 8.1 Ci SI.1 )an$ A.1 an Ihan$ J.1 G@ni'o"m $lo(li+e plasma sou"ce assiste by p"eioni*ation o' spa"+ in ambient ai" at atmosphe"ic p"essu"e1G <pplie 6hysics Cette"s F91 131503 020052.

ISSN: 2250-0359

Volume 4 Issue 1.5 2014

Coblation an overview
Balasubramanian !ia"ara#an Stanle$ %e&i'al Colle"e

(bstra't: !e term 'oblation is &erive& )rom *Controlle& ablation+. !is ,ro'e&ure involves non-!eat &riven ,ro'ess o) so)t tissue &issolution usin" bi,olar ra&io)re-uen'$ ener"$ un&er a 'on&u'tive me&ium li.e normal saline. /!en 'urrent )rom ra&io)re-uen'$ ,robe ,ass t!rou"! saline me&ium it brea.s saline into so&ium an& '!lori&e ions. !ese !i"!l$ ener"i0e& ions )orm a ,lasma )iel& w!i'! is su))i'ientl$ stron" to brea. or"ani' mole'ular bon&s wit!in so)t tissue 'ausin" its &issolution. !is arti'le attem,ts to ,rovi&e a broa& overview o) t!e te'!nolo"$ an& its uses in t!e )iel& o) otolar$n"olo"$. Intro&u'tion: Coblation 1Controlle& ablation2 was )irst &is'overe& b$ 3ira V. !a,li$al an& 4!ili, 5. 5""ers. !is was a'tuall$ a )ortuitous &is'over$ in t!eir -uest )or unblo'.in" 'oronar$ arteries usin" ele'trosur"i'al ener"$. In or&er to mar.et t!is emer"in" te'!nolo"$ t!ese two starte& an u,start 'om,an$ (rt!roCare. Coblation wan&s were e6!ibite& in art!ros'o,$ tra&e s!ow &urin" 1997. Initiall$ 'oblation te'!nolo"$ was use& in art!ros'o,i' sur"eries immensel$ bene)itin" in#ure& at!elets. e'!nolo"$ overview: Coblation te'!nolo"$ is base& on non !eat &riven ,ro'ess o) so)t tissue &issolution w!i'! ma.es use o) bi,olar ra&io )re-uen'$ ener"$ 1. !is ener"$ is ma&e to )low t!rou"! a 'on&u'tive me&ium li.e normal saline. /!en 'urrent )rom ra&io)re-uen'$ ,robe ,asses t!rou"! saline me&ium it brea.s saline into so&ium an& '!lori&e ions. !ese !i"!l$ ener"i0e& ions )orm a ,lasma )iel& stron" enou"! to brea. or"ani' mole'ular bon&s wit!in so)t tissue 'ausin" its &issolution. Sin'e 19508s !i"! )re-uen'$ ele'trosur"i'al a,,aratus !ave been in use. In 'onventional !i"! )re-uen'$ a,,aratus !eat is ma&e use o) to 'ause tissue ablation an& 'oa"ulation. !e !eat "enerate& !a,,ens to be a &ouble e&"e& wea,on 'ausin" 'ollateral &ama"e to normal tissues. Coblation is a'utall$ a bene)i'al o))s!oot o) !i"! )re-uen'$ ra&io )re-uen'$ ener"$. !e e6'ellent 'on&u'tivit$ o) saline is ma&e use o) in t!is te'!nolo"$. !is 'on&u'tivit$ is res,onsible )or !i"! ener"$ ,lasma "eneration. Sta"es o) ,lasma "eneration:

9irst sta"e : 1Va,our "as ,iston )ormation2: !is is '!ara'terise& b$ transition )rom bubble to )ilm boilin". 'auses in'rease in sur)a'e tem,erature. Se'on& sta"e : Sta"e o) va,our )ilm ,ulsation: issue ablation o''urs &urin" t!is sta"e. !ir& sta"e : ;e&u'tion o) am,litu&e o) 'urrent a'ross t!e ele'tro&es. 9ourt! sta"e : <issi,ation o) ele'tron ener"$ at t!e metal ele'tro& sur)a'e 9i)t! sta"e 1sta"e o) t!ermal &issi,ation o) ener"$2: o) ,lasma ions= a'tive atoms an& mole'ules. !is sta"e is essentiall$ &ue to re'ombination !is &e'reases !eat emission an&

!ese sta"es e6,lain w!$ 'oblation is e))e'tive i) a,,lie& intermittentl$. !is ensures 'onstant ,resen'e o) sta"e o) va,our )ilm ,ulsation w!i'! is im,ortant )or tissue ablation. 5))e't o) ,lasma on tissue: !e e))e't o) ,lasma on tissue is ,urel$ '!emi'al an& not t!ermal. 4lasma "enerates 3 an& >3 ions. It is t!ese ions t!at ma.e ,lasma &estru'tive. >3 ra&i'al 'auses ,rotein &e"ra&ation. /!en 'oblation is bein" use& to ,er)orm sur"er$ t!e inter)a'e between ,lasma an& &isse'te& tissue a'ts as a "ate )or '!ar"e& ,arti'les. In nuts!ell 'oblation 'auses low tem,erature mole'ular &isinte"ration. !is 'auses volumetri' removal o) tissue wit! minimal &ama"e to a&#a'ent tissue 2. 1Collateral &ama"e is low2.

<i))eren'es between 'oblation an& 'onventional ele'tro sur"i'al &evi'es

Coblation <evi'es em,eratures !ermal ,enetration 5))e'ts on ar"et tissue 5))e'ts on surroun&in" tissue 40 ? C : @0 ? C %inimal Aentle removal B <issolution %inimal &issolution

Conventional 5le'tro sur"i'al <evi'es 400 ? C : 700 ? C <ee, ;a,i& !eatin"= '!arrin"= burnin" an& 'uttin" Ina&vertant '!arrin" B burnin"

Com,onents o) Coblation s$stem: 1. ;9 "enerator

2. 9oot ,e&al 'ontrol 3. Irri"ation s$stem 4. /an&

9i"ure s!owin" various 'om,onents o) 'oblator

;9 "enerator: !is "enerator "enerates ;9 si"nals. It is 'ontrolle& b$ mi'ro,ro'essor. !is "enerator is 'a,able o) a&#ustin" t!e settin"s as ,er t!e t$,e o) wan& inserte&. It automati'all$ senses t!e t$,e o) t!e wan& an& a&#usts settin"s a''or&in"l$. %anual overri&e o) t!e ,reset settin"s is also ,ossible. wo settin"s are set i.e. 'oblation an& 'auteri0ation. 9or a tonsil wan& t!e re'ommen&e& settin"s woul& be : Coblation : @ 1,lasma settin"2 Cauteri0ation : 3 1Non ,lasma settin"2 Similarl$ t!e )oot ,e&al !as two 'olor 'o&e& ,e&als. Cellow one is )or 'oblation an& t!e blue one is )or ;9 'auter$. !is &evi'e also emits &i))erent soun&s w!en t!ese ,e&als are ,resse& in&i'atin" to t!e sur"eon w!i'! mo&e is "ettin" a'tivate&. 5ven t!ou"! 'oblation is a t$,e o) ele'tro sur"i'al ,ro'e&ure= it &oes not re-uire 'urrent )low t!rou"! t!e tissue to a't. >nl$ a small amount o) 'urrent ,asses t!rou"! t!e tissue &urin" 'oblation. issue ablation is ma&e ,ossible b$ t!e '!emi'al et'!in" e))e't o) ,lasma "enerate& b$ wan&. !e t!i'.enss o) ,lasma is onl$ 100-200 Dm t!i'. aroun& t!e a'tive ele'tro&e. >tolar$n"olo"i'al sur"eries w!ere 'oblation te'!nolo"$ !as been )oun& tobe use)ul in'lu&e:

1. (&enotonsille'tom$ 2. on"ue base re&u'tion 3. on"ue '!annelin" 4. Evulo ,alato ,!ar$n"o,last$ 5. Cor&e'tom$ 7. ;emoval o) beni"n lesions o) lar$n6 in'lu&in" ,a,illoma @. Fas!ima8s ,ro'e&ure )or bilateral ab&u'tor ,aral$sis G. urbinate re&u'tion 9. Nasal ,ol$,e'tom$ !ere are &i))erent t$,es o) wan&s 3 available to ,er)orm 'oblation ,ro'e&ure o,timall$. onsil an& a&enoi& wan& is t!e 'ommonl$ use& wan& )or all oro,!ar$n"eal sur"eries. will !ave to be bent sli"!tl$ to rea'! t!e a&enoi&. !is wan&

Har$n"eal wan& is o) two t$,es. Normal lar$n"eal wan& w!i'! is use& )or ablatin" lar$n"eal mass lesions. %ini lar$n"eal wan& is use& to remove small ,ol$,s )rom vo'al )ol&s. !e main a&vanta"e o) mini lar$n"eal wan& is its abilit$ to rea'! u, to t!e sub"lotti' area. Nasal wan& an& nasal tunellin" wan&s are 'ommonl$ use& )or turbinate re&u'tion. Se,erate tunellin" wan&s are available )or ton"ue base re&u'tion. 5-ui,ment s,e'i)i'ation: 1. %o&es o) o,eration : <isse'tion= ablation= an& 'oa"ulation 2. >,eratin" )re-uen'$ : 100 .!0 3. 4ower 'onsum,tion : 110B240 v= 50B70 F!0

<ia"ramati' re,resentation o) 'oblation wan& Coblation wan& !as two ele'tro&es i.e. Base ele'tro&e an& a'tive ele'tro&e. !ese ele'tro&es are se,arate& b$ 'erami'. Saline )lows between t!ese two ele'tro&es. Current "enerate& )lows between t!ese two ele'to&es via t!e saline me&ium. Saline "ets bro.en &own into ions t!ereb$ )ormin" a'tive ,lasma w!i'! ablates tissue.

5))i'ien'$ o) ablation 'an be im,rove& b$: 1. Intermittent a,,li'ation o) ablation mo&e 2. Co,ious irri"ation o) normal saline 3. B$ usin" 'ol& saline ,lasma "enerate& be'omes more e))i'ient in ablatin" tissue. Col& saline 'an be ,re,are& b$ ,la'in" t!e saline ,a'. in a re)ri"erator over ni"!t. Coblation is a smo.elessa ,ro'e&ure. I) smo.e is seen to be "enerate& &urin" t!e ,ro'e&ure it in&i'ates t!e ,resen'e o) ablate& tissue in t!e wan& between t!e ele'tro&es. 3en'e a smo.in" wan& s!oul& be )lus!e& usin" a s$rin"e to remove so)t tissue ablate& ,arti'les between t!e ele'tro&es. !e "enerate& )re-uen'$ )rom 'oblator s!oul& atleast be 200 .30 sin'e )re-uen'ies lower t!an 100 .30 'an 'ause neuromus'ular e6'itation w!en t!e wan& a''i&entall$ 'omes into 'onta't wit! neuromus'ular tissue. Con'lusion: (ut!or wis!es to 'on'lue t!at 'oblation is a ,romisin" te'!nolo"$ in otolar$n"olo"$. >) 'ourse as wit! an$ ot!er te'!nolo"$ it !as t!e 'ost )a'tor built into it. !e 'ost o) wan& w!i'! is meant )or sin"le use is rat!er !i"!. !is e-ui,ment is ver$ use)ul )or ablatin" lar$n"eal lesions. (s )ar as a&enotonsille'tom$ is 'on'erne& it a&&s to t!e 'ost o) t!e sur"i'al ,ro'e&ure. 4er)ormin" tonsille'tom$ usin" 'oblation !el,s t!e sur"eon to 'ross t!e learnin" 'urve rat!er easil$. !is te'!nolo"$ !as a learnin" 'urve to surmount. ()ter "ettin" over t!e 'urve a sur"eon 'an e))i'ientl$ !an&le lar$n"eal lesions an& obstru'tive slee, a,noea wit! ease.

;e)eren'es: 1. I./olos0.o an& C.Ailbri&e=Coblation e'!nolo"$:4lasma %e&itation (blation )or >tolar$n"olo"$ (,,li'ations=;e,.(rt!ro Care Cor,.=Sunn$vale120012=,,102114. 2. S.V Belov= Ese o) 3i"!-9re-uen'$ Col& 4lasma (blation e'!nolo"$ )or 5le'trosur"er$ wit! %inimi0e& Invasiveness=Biome&i'al 5n"ineerin"=Vol3G=no2=2004=,,G0-G5. 3. V.N Ser"eev= S.V.Belov Coblation e'!nolo"$:a New %et!o& )or 3i"! 9re-uen'$ 5le'trosur"er$=Biome&i'al 5n"ineerin"=Vol3@=No 1=2003=,,22-25.

ISSN: 2250-0359

Volume 4 Issue 1.5 2014

Kashima's Posterior cordectom usi!" coa#lator our e$%erie!ce.


&alasu#rama!ia! 'hia"ara(a! Vri!da &ala)rish!a! Nair Sta!le *edical +olle"e

,#stract: ,im: 'o stud the e--ecti.e!ess o- co#latio! tech!olo" i! %er-ormi!" Kashima's %rocedure -or #ilateral a#ductor .ocal -old %aral sis. *ethodolo" : *a!a"i!" %atie!ts /ith #ilateral .ocal -old a#ductor %aral sis is rather tric) o!e. It calls -or delicate #ala!ce #et/ee! air/a a!d %ho!atio!. Various e!dolar !"eal tech!i0ues ha.e #ee! used to ma!a"e this %ro#lem. 1ere the authors descri#e their e$%erie!ce /ith %osterior cordectom usi!" coa#lator. 'his stud i!cludes 10 %atie!ts /ho %rese!ted /ith stridor -ollo/i!" #ilateral a#ductor %aral sis. ,ll our %atie!ts /ere o! tracheostom tu#es. 'he /ere .er a!$ious /ith the tu#e a!d /a!ted deca!!ulatio! do!e. ,ll o- these %atie!ts /ere o%erated # the same se!ior sur"eo!. 'hese %atie!ts /ere ma!a"ed /ith %osterior cordotom usi!" coa#latio!. 2ar !"eal /a!ds /ere used i! all these %atie!ts. 'hese %atie!ts u!der/e!t s%i""oti!" o- their tracheostom tu#e o! the -irst %ost o%erati.e da . 3eca!!ulatio! /as com%leted o! the third %ost o%erati.e da . 4arl deca!!ulatio! /as made %ossi#le #ecause there /as !e"li"i#le so-t tissue oedema as these %atie!ts u!der/e!t co#latio! %rocedure. 5#ser.atio!: 5! dischar"e all o- them had a "ood .oice a!d ade0uate air/a . 'hese %atie!ts /ere a#le to clim# t/o -li"hts o- stairs /ithout discom-ort.

,lthou"h the causes o- #ilateral a#ductor %aral sis o- .ocal cords are multi-actorial %ost traumatic %aral sis -ormed a lar"e ma(orit o- our %atie!ts 6 7 /ho de.elo%ed #ilateral .ocal -old %aral sis -ollo/i!" total th roidectom 8.

I!troductio!: &ilateral .ocal -old immo#ilit is a rather commo! #ilateral .ocal -old immo#ilit s !drome. 'his is commo!l caused due to dama"e to #oth recurre!t lar !"eal !er.es. 4m#r olo" has made the course o- recurre!t lar !"eal !er.es 6!er.e o- the 9th #ra!chial arch8 rather com%licated a!d hi"hl .ari#le. +auses o- #ilateral a#ductor .ocal -old %aral sis i!clude 1: 1. Sur"ical 6+ommo!l -ollo/i!" %ost th roidectom 8 close to 59: i! some studies. 2. I!tu#atio! a#out 25: 3. 'rauma 2: 4. Neurolo"ical disorders 15: 5. 4$tra lar !"eal mali"!a!cies 5-1;: 2 +li!cial -eatures o- #ilateral a#ductor %aral sis o- .ocal -olds: 1. Stridor due to air/a com%romise 2. Near !ormal .oice 3 s%!oea ma #e .ar i!" i! de"ree de%e!di!" o! 3: 1. ,mou!t o- "lottic chi!) 2. ,r te!oid #od mass 3. Prese!ce < a#se!ce o- comor#idit 4. Ph sical acti.it 10: o- these %atie!ts !eed !o i!ter.e!tio!. Some o- them could decom%e!sate ma)i!" them d s%!oeic 4. =or ce!turies tracheostom has #ee! the "old sta!dard i! the ma!a"eme!t o- #ilateral a#ductor .ocal -old %aral sis. ,ll the %rocedures are com%ared /ith trachestom to ascertai! their e--icac . I!troductio! o- Klei!sasser sus%e!sio! lar !"osco%e re.olutio!ised e!dolar !"eal sur"ical %rocedures a!d treatme!t o- #ilateral a#ductor .ocal -old %aral sis.

>esults: 'otal !um#er o- %atie!ts ta)e! u% -or stud ? 10 =emale ? ; *ale ? 3

=i"ure sho/i!" se$ distri#utio! amo!" %atie!ts /ith #ilateral a#ductor .ocal -old %aral sis

=i"ure sho/i!" a"e distri#utio! o- %atie!ts /ith #ilateral a#ductor %aral sis *a(orit o- our %atie!ts /ere i! the 4th decade o- li-e.

=i"ure sho/i!" the .arious etiolo"ical -actors that caused #ilateral a#ductor %aral sis i! our stud "rou%

Iatro"e!ic causes o- #ilateral a#ductor .ocal -old %aral sis /as commo! i! our stud "rou%. ,lmost all o- these %atie!ts u!der/e!t total th roidectom . Patie!ts i! this stud /ere o! tracheostom -or %eriods ra!"i!" -rom 2 @ 10 ears. No!e o- them tolerated s%i"otti!" o- the tracheostom tu#e. 3eca!ulatio! %rocedure /as attem%ted i! all o- these %atie!ts #ut -ailed. Procedure: 'he sur"ical %rocedure i!troduced # 3e!!is a!d Kashima i! 1979 re.olutio!ised the ma!a"eme!t o- #ilateral a#ductor .ocal -old %aral sis. 'his tech!i0ue is #ased o! resectio! o- so-t tissues a!d tra!sectio! o- co!us elasticus. , A+B Sha%ed /ed"e o- %osterior .ocal -old is e$cised #e"i!i!" -rom the -ree #order a!d e$te!di!" to a#out 4mm laterall . &asic ratio!ale i! this %rocedure is the release o- te!sio! o- the "lottic s%hi!cter rather tha! actual remo.al o- "lottic tissue. I- air/a is !ot ade0uate the! the same %rocedure ca! #e carried out o! the o%%osite side also. >e)er a!d >udert modi-ied the ori"i!al Kashima %rocedure /hich i!.ol.ed com%leme!tar resectio! i! the #od o- lateral th roar te!oid muscle a!teriorl -rom the i!itial tria!"ular i!cisio!. 'his %roduced a lar"er air/a /ith "ood .oice. 9 o- our %atie!ts u!der/e!t the classic Kashima %rocedure /hile o!e %atie!t u!der/e!t >e)er's %rocedure 9.

3ia"ram sho/i!" the site o- resectio! i! Kashima's %rocedure

=i"ure sho/i!" >ec)er's modi-icatio! o- Kashima's %rocedure

Si!ce all our %atie!ts /ere o! tracheostom C the same stoma /as used -or i!tu#atio! -or a!esthesia %ur%oses. D!der "e!eral a!esthesia Klei!sasser lar !"osco%e is used to e$%ose the lar !"eal i!let. +o#alator /as used -or this %rocedure. 2ar !"eal /a!d /as used to resect the %osterior %ortio! othe .ocal -old.

=i"ure sho/i!" Kashima's sur"er usi!" lar !"eal /a!d

=i"ure sho/i!" Kashima's sur"er a-ter com%letio! o- the %rocedure

=i"ure sho/i!" >e)er's modi-icatio! o- )ashima's %rocedure

+o!clusio!: Per-ormi!" Kashima's %rocedure usi!" co#latio! tech!olo" is reall %romisi!". ,d.a!ta"es othis %rocedure i!clude: 1. &lood less a#latio! 2. Precise a#latio! o- tissue 3. No collateral dama"e to ad(ace!t tissue 4. No oedema o- tissues arou!d lar !$ 5. 4arl deca!ulatio! is %ossi#le

>e-ere!ces: 1. &e!!i!"er *SC Eille! F&C ,ltma! FS 619978 +ha!"i!" etiolo" o- .ocal -old immo#ilit . 2ar !"osco%e 107:1349@1350 2. 2eo! GC Ve!e"as *PC 5rus +C Huer *C *ara!illo 4C Sa!udo F> 620018 I!mo.ilidad "lotica: estudo retros%ecti.o de 299 casos. ,cta 5torri!olari!"ol 4s% 52:479@492 3. Klei!sasser 5C Nolte 4 619718 4!dolar !"eale ,r tae!oide)tomie u!d su#mu)Ise %artielle +horde)tomie #ei #ilaterale! Stimmli%%e!lJhmu!"e!. 2ar !"orhi!ootolo"ie 90:39;@401 4. Sessio!s 3EC 5"ura F1C 1ee!ema! 1 619;98 Sur"ical ma!a"eme!t o- #ilateral .ocal cord %aral sis. 2ar !"osco%e 79:559@599 5. 3e!!is 3PC Kashima 1. +ar.o! dio$ide laser %osterior cordotom -or treatme!t o- #ilateral .ocal cord %aral sis. ,!! 5tol >hi!ol 2ar !"ol. 1979C 97:930-934. 9. >e)er DC >udert 1 619978 3ie modiKLierte %osteriore +hordectomie !ach 3e!!is u!d Kashima #ei der &eha!dlu!" #eidseiti"er >e)urre!s%arese!. 2ar !"orhi!ootolo"ie ;;:213@217

ISSN 2250-0359

Volume 4 Issue 1.5 2014

Coblation Tonsillectomy our ex erience


!alasubramanian T"ia#ara$an Stanley %e&ical Colle#e

'bstract( Tonsillectomy "a ens to be t"e commonly er)orme& sur#ery t"ese &ays. *i+e any ot"er sur#ical roce&ure t"is sur#ical roce&ure "as also un&er#one tremen&ous tec"nolo#ical c"an#es. ,ne suc" e-ol-in# c"an#e "a ens to be coblation tonsillectomy. Coblation tec"nolo#y is actually an o))s"oot o) ra&io)re.uency sur#ery. T"is tec"ni.ue in-ol-es assin# ra&io)re.uency ener#y t"rou#" a con&ucti-e me&ium li+e isotonic so&ium c"lori&e or otassium c"lori&e solution. T"is ro&uces a lasma )iel& /"ic" is com ose& o) so&ium an& "y&roxyl ions /"ic" ablates tissue. T"is tissue ablation ta+es lace at 010-203 C4 /"ic" is muc" lo/er t"an t"at ac"ie-e& &urin# ot"er electro sur#ical tec"ni.ues 0400 5 1003 C4. T"is article attem ts to &iscuss t"e use o) t"is tec"nolo#y to er)orm tonsillectomy /it" s ecial em "asis on s"arin# our ex erience /it" t"e system. T"is stu&y in-ol-es critical a raisal o) 25 coblation tonsillectomy sur#eries er)orme& at Stanley %e&ical colle#e &urin# t"e year 2013. Intro&uction( Tonsillectomy still remains t"e commonly er)orme& sur#ical roce&ure. Sur#ical tec"ni.ue o) tonsillectomy "as un&er#one ra i& e-olution since t"e time o) Celsus 30 !C /"o is cre&ite& /it" t"e )irst &ocumente& tonsillectomy roce&ure. 6oo+ an& +ni)e met"o& 1 er)orme& by 'etius o) 'mi&a &urin# 1t" century s"ou& be consi&ere& as t"e )irst scienti)ic attem t at remo-in# tonsils. 7aul o) 'e#ina use& )orce s to com letely extri ate tonsils. T"is lai& t"e )oun&ation )or tonsil #uillotine. 8eor#e 9arnest :au#" o) 9n#lan& /as t"e )irst to use care)ul &issection met"o& to remo-e t"e tonsil. 6e is also cre&ite& /it" t"e &esi#n o) :au#";s tenaculum )orce s /"ic" "e use& to &issect tonsil out o) its be& 019094. Inno-ations t"at too+ lace li+e t"e use o) &iat"ermy< "armonic scal el< &ebri&er /ere meant to re&uce t"e o eratin# time an& blee&in# &urin# t"e roce&ure. Currently coblation is bein# attem te& to remo-e tonsillar tissue. T"is rocess /as in-ente& by 7"ili 9 9##ers an& 6ira V T"a liyal in 1999. Coblation tonsillectomy recei-e& =>' a ro-al in 2001. 3

'&-anta#es o) coblation tonsillectomy( 1. *ess blee&in# 2. 7reser-ation o) ca sule is ossible i) &one un&er ma#ni)ication. I) ca sule is reser-e& t"ere is less ost o erati-e ain 3. Tonsillar re&uction sur#eries can be er)orme& in youn# c"il&ren /it"out com romisin# t"e immunolo#ical )unction o) t"e lym "oi& tissue

T"e tec"nolo#y( Coblation in-ol-es assin# a ra&io)re.uency bi olar electrical current at a muc" lo/er )re.uency t"an t"at o) stan&ar& bi olar &iat"ermy< t"rou#" a me&ium o) normal saline /"ic" results in t"e ro&uction o) lasma )iel& o) so&ium ions. T"ese ions brea+s&o/n intercellular ban&s an& in e))ect -a ori?e tissue at a tem erature o) only 10&e#rees c. T"e resence o) saline "el s to limit t"e amount o) "eat &eli-ere& to t"e surroun&in# structures an& "ence re&uces collateral tissue &ama#e an& causes less ost o ain. T"is is truely a bi olar system an& &oes not nee& eart" a&. %et"a&olo#y( T"is stu&y in-ol-es 25 atients /"o un&er/ent coblation tonsillectomy. T"ey /ere com are& /it" atients /"o un&er/ent col& steel tonsillectomy. T"is is a retros ecti-e stu&y in-ol-in# 25 atients /"o un&er/ent coblation tonsillectomy by a sin#le sur#eon 0t"e aut"or4. T"e results /ere com are& /it" t"at o) col& steel tonsillectomy sur#ery er)orme& by t"e same sur#eon. Selection criteria( 1. @an&om selection o) atients by &ra/ o) lots 2. C"il&ren o) t"e a#e #rou bet/een 5-10 constitute& t"e sub$ects o) stu&y 3. T"is stu&y in-ol-e& 50 atients out o) /"om 25 un&er/ent coblation tonsillectomy /"ile t"e rest un&er/ent con-entional col& steel tonsillectomy. >ata ta+en )or analysis inclu&e( 1. '#e 2. 'mount o) bloo& loss 3. 7ain score 4. 7ost o erati-e blee&in# =ollo/ u /as re)orme& by a secon& sur#eon /"o &i& not +no/ /"at roce&ure /as )ollo/e& &urin# tonsillectomy. 9ac" o) t"ese atients /ere as+e& to )ill u a .uestionaire /"ic" cotaine& s eci)ic .uestions relatin# to t"e time ta+en )or t"em to return bac+ to normal li)e.

Statistical tools /ere not use& to analy?e t"e &ata because t"e stu&y number /as small.

@esults( Total number o) cases ta+en u )or stu&y A 50 Number o) atients /"o un&er/ent coblation tonsillectomy A 25 Number o) atients /"o un&er/ent con-entional col& steel tonsillectomy A 25 '-era#e '#e &istribution o) atients /"o un&er/ent coblation tonsillectomy /as A 2.11 '-era#e '#e &istribution o) atients /"o un&er/ent con-entional col& steel tonsillectomy A 2.2 '#e &istribution bet/een t"e t/o stu&y cate#ories /ere more or less similar.

=i#ure s"o/in# a#e &istribution bet/een t/o stu&y #rou s

'ssessment o) bloo& loss &urin# t"ese t/o roce&ures( Cotton balls an& #au?e lanne& to be use& &urin# sur#ery s"oul& be care)ully /ei#"e& be)ore autocla-in#. Bse& cotton an& #au?e s"oul& be /ei#"e& an& t"e &i))erence in /ei#"t is an assessment o) bloo& containe& in t"em. T"e &i))erence in /ei#"t can be con-erte& into milliliters by &i-i&in# t"e &i))erence in /ei#"t by s eci)ic #ra-ity 01.0554. 4 Saline ta+en in t"e bo/l is measure& an& +e t at 150 ml. T"is -olume is use& to +ee t"e suction tube unclo##e&. T"is -olume s"oul& be subtracte& )rom t"e -olume o) bloo& insi&e t"e suction bottle. T"is -olume a&&e& to t"e -olume o) bloo& loss estimate& )rom cotton an& #au?e #i-es t"e -olume o) bloo& loss &urin# t"e roce&ure. 'll atients /ere reme&icate& /it" in$ection atro ine /"ic" "el e& in re&ucin# normal sali-ary secretions. ,ral ca-ities o) t"ese atients /ere cleane& &ry usin# #au?e be)ore t"e start o) roce&ure. '-era#e bloo& loss o) t"ese atients /as( Coblation tonsillectomy A C1 ml Col& steel tonsillectomy A 90 ml T"ese -alues in&icate t"at t"ere /as no a reciable &i))erence in bloo& loss bet/een t"ese t/o #rou s.

=i#ure s"o/in# com arison o) bloo& loss bet/een coblation an& col& steel tonsillectomy #rou s

7ain score( 7ain score /as calculate& usin# :on#-!a+er ='C9S 7ain @atin# scale. ,ne c"il& o) a#e 3 /"o un&er/ent tonsillectomy /as exclu&e& )rom t"e stu&y since t"e res onse /as unreliable. T"e c"il& is s"o/n ima#e containin# 1 )aces an& is as+e& to c"oose /"ic" best &escribes "is D "er current )eelin#.

Coblation tonsillectomy #rou ( 1. 1 atients c"oose ima#e 2 2. 10 atients c"oose ima#e 3 3. C atients c"oose ima#e 4 1 atient /as exclu&e& since t"e c"il& /as 3 years ol& Col& steel tonsillectomy #rou ( 1. 10 atients c"oose ima#e 5 2. 4 atients c"oose ima#e 4

3. 2 atients c"oose ima#e 3 4. 9 atients c"oose ima#e 1

7ain score in coblation #rou

7ain score in col& steel tonsillectomy #rou

7ain scores /ere )oun& to be rat"er "i#" in atients /"o un&er /ent col& steel tonsillectomy. T"is coul& be attribute& to t"e extraca sular &issection /"ic" is &one in coblation. *ea-in# be"in& tonsillar ca sule "as been ostulate& to re&uce ain because t"ere is less muscle ex osure an& irritation. 7ain &ue to tonsillectomy "as been attribute& &ue to "aryn#eal muscle s asm /"ic" is commonly seen /"en t"e muscle )ibers are ex ose&. 7ost o erati-e blee&in#( ,ur stu&y &i& not s"o/ any ost o erati-e blee&in# in t"e col& steel tonsillectomy #rou . ,ne atient belon#in# to coblation #rou &e-elo e& secon&ary blee&in# on t"e Ct" &ay )ollo/in# sur#ery. 7atient reco-ere& on bein# treate& /it" antibiotics 5. Noon et al in t"eir stu&y "a-e re orte& a #reater inci&ence o) ost o blee&in# in atients /"o "a-e un&er#one coblation tonsillectomy. 1 T"ey attribute& t"is to t"e )ormation o) "ealt"y #ranulation tissue in t"e tonsillar )ossa /"ic" "a& a ten&ency to blee& e-en on tri-ial trauma. >iscussion( Coblation tonsillectomy is a recent inno-ation. It "as e-o+e& a lot o) curiosity amon# otolaryn#olo#ists. Tonsillectomy "as been er)orme& commonly /orl&/i&e. 2 9x erience /it" coblation is .uite recent. %ore an& more literature is bein# #enerate& /orl& /i&e by eo le usin# t"is tec"nolo#y. 9-en t"ou#" t"is stu&y is limite& by t"e number o) atients stu&ie&< it #i-es a clear ointer to one as ect i.e. coblation tonsillectomy causes less ost o erati-e ain /"en com are& to con-entional col& steel roce&ure. T"is is &ue to t"e )act t"at tonsillectomy

usin# t"is roce&ure is extraca sular. >ebul+in# o) enlar#e& tonsils can also be er)orme& reser-in# t"e immunolo#ical )unctions o) t"e tonsils. T"is stu&y s"o/e& no e-i&ence o) lesser ost o erati-e blee&in# bet/een t"e t/o #rou s un&er stu&y. Conclusion( Coblation is a romisin# tec"nolo#y )or otolaryn#olo#ical use. %a$or a&-anta#e t"e aut"or notice& /"ile er)ormin# tonsillectomy is re&uce& ost o erati-e ain scores. 7atients starte& eatin# /it" -ery little &iscom)ort )ollo/in# sur#ery. ' more com re"esi-e stu&y /oul& t"ro/ more li#"t on t"is tec"nolo#y.

=i#ure s"o/in# coblation tonsillectomy bein# er)orme&

@e)erences( 1. Curten E%( T"e "istory o) tonsil an& a&enoi& sur#ery. ,tolo#y Clinics Nort" 'merica 19C2F20(415. 2. Gaem el E'. ,n t"e ori#in o) tonsillectomy an& &issection met"o&< *aryn#osco e 2002 F 112(15C3-15C1. 3. Tem le @6< Timms %S. 7ae&iatric coblation tonsillectomy. Int E 7e&iatr ,tor"inolaryn#ol 2001F 11034( 195-C. 4. "tt (DD///.ncbi.nlm.ni".#o-D mcDarticlesD7%C3222C30D 5. *ee GC< 'ltenau %%< !arnes >@< !ernstein E%< !i +"a?i N!< !rettsc"ei&er ='< et al. Inci&ence o) com lications )or subtotal ioni?e& )iel& ablation o) t"e tonsils. ,tolaryn#ol 6ea& Nec+ Sur# 2002F 122014( 531-C. 1. Noon '7< 6ar#rea-es S. Increase& ost-o erati-e "aemorr"a#e seen in a&ult coblation tonsil lectomy. E *aryn#ol ,tol 2003F 112094( 204-1.

2. %ann >8< St 8C< Sc"einer 9< 8rano)) >< Imber 7< %lynarc?y+ ='. Tonsillectomy--some li+e it "ot. *aryn#osco e 19C4F 9405 7t 14( 122-9.

ISSN 2250-0359

Issue 4 Volume 1.5 2014

Coblation wands

Balasubramanian Thiagarajan Stanley Medical College

Abstract: This article discusses the architecture of coblation wands used in otolaryngological surgeries. Wand happens to be the most important consumable of the coblation system. These wands are also expensive and meant only for single use. Hence this technology has a built in recurring cost factor.

Introduction: There are different wands available for different surgical procedures. These wands include:

1. 2. 3. 4. 5.

Tonsil wand Laryngeal wand Microlaryngeal wand Nasal wand Needle wands for tongue base reduction and turbinate reduction

Tonsil wand: This wand is also known as Evac 70 wand. It has a triple wire molybdenum electrode. This triple wire electrode is very useful for tissue ablation. Its bipolar configuration suits efficient hemostasis. The shaft is malleable and hence can be bent to suit various anatomical configurations of oral cavity. It can also be bent so much that adenoids can be reached via the

oral cavity route under the soft palate. It has integrated suction and irrigation facility. Normal saline is used for irrigation purposes. Normal saline acts as a medium through which Radio frequency current passes causing release of plasma. This integrated irrigation and suction facility obviates the necessity of separate suction during surgical procedures.

Figure showing Tonsil wand

Tonsil wand happens to be the work horse of the entire system. It is also the most commonly used wand. The basic advantages of tonsil wand are:

1. Plasma generated by the electrodes are optimized for adequate tissue ablation 2. The depth of injury is very less and hence there is no collateral tissue damage

3. The temperature generated between the electrodes is 40-70 C. This temperature does not cause airway fire and it is hence safe to use. 4. The presence of multiple electrodes ensures quick and stable establishment of plasma layer, maintains the stability of the plasma layer and also maximizes the plasma layer.

Figure showing tonsillar wand in action Microlaryngeal wand:

This wand is designed for precise and controlled ablation of laryngo tracheal lesions. Its shaft is thin and long. It provides ablation, coagulation, suction and irrigation in the same set up. Its increased length facilitates tissue ablation from the anterior commissure of larynx and upper trachea. It also does not obstruct vision of the surgeon.

Figure showing Microlaryngeal wand

Laryngeal wands: This wand is very useful for controlled ablation of bulky or sessile laryngeal lesions. It has built in ablation, irrigation, coagulation and suction capabilities. The length of this wand is suitable for ablating lesions from larynx and anterior commissure areas. Its curvature does not obstruct vision. It does not have the risk of air way fires which is possible with conventional electro surgical equipment.1

Figure showing laryngeal wand in action

Turbinate reduction wand: This wand is a needle type wand. Saline should be infiltrated into the turbinate tissue before performing the actual procedure. This wand does not have an irrigation portal hence the tissue needs to be infiltrated with a mixture of 2% xylocaine with I in 100,000 units adrenaline admixed with normal saline. These wands are also known as Reflex Ultra wands. These wands are designed to perform minimally invasive procedures. Sub mucosal channeling procedures can be performed using this wand 2. Reflex Ultra 45 is used for turbinate reduction 3.

Tongue base reduction wand: Reflex Ultra 55 wand is used for tongue base reduction and soft palate reduction. This is usually performed to treat snoring.

Figure showing Reflex Ultra wand

All these reflex ultra channeling wands have depth limiters. This helps in limiting the depth of sub mucosal penetration.

Figure showing Reflex ultra wand with depth limiter

Coblation wands can work in two settings: 1. Non plasma power setting 2. Plasma power setting

Differences between Non plasma and Plasma power settings:

Non Plasma power setting 1-5 No plasma layer is formed Tissue not removed Deeper depth of penetration Lower voltages used Temperature generated is more Cellular vibration / oscillation

Plasma power setting 6-9 Plasma layer is formed Tissue removed Shallow depth of penetration Higher voltages used Temperature generated is less Molecular dissociation

The color of Plasma glow generated at the tip of the wand varies depending on the medium used for irrigation. The tip of the wand glows yellow if sodium chloride is used as irrigation medium and orange if the irrigation medium happens to be potassium chloride solution.

Tips: 1. Copious irrigation with normal saline is a must 2. Colder the irrigating fluid better is the result (overnight refrigeration of saline packs is preferable) 3. Plasma power setting should be used for best results 4. Wand should not dig into the tissue 5. Wands are meant for single use only. Multiple uses not only fails to generate plasma but also causes increased incidence of wound infection 6. Wands should be handled with extreme care to make it last till the end of the case

References: 1. Matt BH, Cottee LA. Reducing risk of fire in the operating room using Coblation technology. Otolaryngol Head Neck Surg. 2010 Sept;143(3):454-5 2. Bhattacharyya N, Kepnes LJ. Clinical effectiveness of Coblation inferior turbinate reduction. Otolaryngol Head Neck Surgery. 2003;129:365-371. 3. Bck LJJ, Hytnen ML, Malmberg HO, Ylikoski JS. Submucosal bipolar radiofrequency thermal ablation of inferior turbinates: A long-term follow-up with subjective and objective assessment. The Laryngoscope, 2002; 112: 1806-1812.

ISSN: 2250-0359

Volume 4 Issue 1.5 2014

Coblation adenoidectomy our experience

Balasubramanian Thiagarajan Vrinda Balakrishnan Nair Stanley Medical College

Abstract: Aim of our study is to compare the efficacy and safety of coblation adenoidectomy versus conventional cold steel adenoidectomy. The study design included 40 children between age groups 4 8. Twenty of these children underwent coblation adenoidectomy while the other group of 20 underwent conventional cold steel adenoidectomy. The parameters taken into consideration for comparison included Post operative pain, operating time, intraoperative bleeding and presence of residual adenoid tissue 6 weeks after surgery. In this study the coblation group demonstrated less post operative pain, less intraoperative bleeding and more complete removal of adenoid tissue. Operative time was found to be significantly higher in coblation group when compared to conventional cold steel adenoidectomy group.

Introduction: Adenoid is the lymphoid aggregation seen in the nasopharyx. This tissue is a component of inner waldayers ring. This tissue undergoes hypertrophy till the child reaches the age of 4 after which the proportional increase of the size of nasopharyx makes it appear reduced in size which

is followed by a reduction of symptoms. Adenoidectomy is the commonly performed surgery in children. As with any other surgical procedure there are complications associated with adenoidectomy. These complications are fortunately rare 2. Various methods of performing adenoidectomy include: 1. 2. 3. 4. Conventional cold steel technique using curette Bipolar coagulation under endoscopic vision Adenoidectomy using microdebrider 3 Coblation adenoidectomy

For purposes of classification and management adenoid hypertrophy has been graded according to the size of the tissue taking into consideration the relationship of the hypertrophied tissue with vomer, soft palate and torus tubaris 4.

Grade Grade I Grade II Grade III Grade IV Materials and methods:

Anatomical structure in contact with adenoid tissue None Torus tubaris Torus tubaris, Vomer Torus tubaris, Vomer and soft palate at rest

Pediatric patients of age group ranging between 4 and 8 were included in the study. Parents of the children taken up for study were not aware of the procedure followed during surgery. Patients were chosen randomly for the procedure by an intern by draw of lots. This random choice averted surgeon bias 5 6. All the surgical procedures were performed by the same surgeon. Children with co morbid conditions like anemia, upper and lower respiratory infections were excluded from the study. The size of adenoid tissue was graded using the grading system discussed above. Size of adenoid is assessed by performing diagnostic nasal endoscopic examination under topical anesthesia.

Age distribution of patients who underwent coblation adenoidectomy

Age distribution of patients who underwent cold steel adenoidectomy

Procedure: Cold steel adenoidectomy was performed in a classic manner using conventional instruments. Blood loss is calculated by weighing the gauze pre operatively and post operatively. Gauze should be weighed before sending them for autoclaving. Coblation adenoidectomy was performed by putting the patient in head up position. Soft palate is retracted by passing a soft rubber catheter via the nasal cavity. Adenoid tissue is visualized by passing a 0 degree 2.7 mm nasal endoscope. Oral cavity is kept open by using a Boyles Davis mouth gag. Tonsillectomy wand is bent in such a way that it could be passed under the soft palate. Coblation of adenoid tissue is performed under visualization. Adenoid is ablated till the prevertebral fascia becomes visible. Adenoid tissue behind the tubal orifice can also be ablated.

Image showing ablation of adenoid tissue using coblation

Result:

Bleeding after conventional adenoidectomy was higher than that of bleeding after coblation tonsillectomy. On an average blood loss following conventional adenoidectomy was 50 ml while it was 20 ml for coblation adenoidectomy. Operating time of coblation adenoidectomy was significantly higher than that of conventional adenoidectomy. On an average it took 20 minutes to perform coblation adenoidectomy while it took just 5 7 minutes to perform conventional adenoidectomy. Amount of residual adenoid tissue was assessed in both categories of patients by performing nasal endoscopy using 2.7 mm 0 degree nasal endoscope in all these patients. The amount of residual adenoid tissue was significantly higher in conventional adenoidectomy when compared to that of coblation technique.

Conclusion: Coblation technique ensures complete removal of adenoid tissue with minimal bleeding. This helps in early resolution of secretary otitis media. Adenoid tissue present behind the tubal tonsil can also be removed safely using coblation technique. Coblation technique does not exert undue pressure over atlanto occipital joint because the patient is not put in Rose position and the wand also does not exert pressure over the area. Incidence of Grisel syndrome in both these groups will make an interesting study provided it includes a large study group.

References: 1. Gallagher TQ, Wilcox L, McGuire E, et al. Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques. Otolaryngol Head Neck Surg 2010;142:886-92 2. Regmi D, Mathur NN, Bhattarai M. Rigid endoscopic evaluation of conventional curettage adenoidectomy. J Laryngol Otol 2011;125:53-8 3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3266095/ 4. Validation of a new grading system for endoscopic examination of adenoid hypertrophy Sanjay R. Parikh, MD, Mark Coronel, MD, James J. Lee, MD, and Seth M. Brown, MD, New York, New York OtolaryngologyHead and Neck Surgery (2006) 135, 684-687 5. http://www.ncbi.nlm.nih.gov/pubmed/18650626 6. Horwitz RI, McFarlane MJ, Brennan TA, et al. The role of susceptibility bias in epidemiologic
research. Arch Intern Med. 1985;145:909-912.