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Avoiding oral burns during electrocautery tonsillectomy.

Abstract
Electrocautery tonsillectomy is a common method of tonsil removal,
and electrocautery devices are widely available. Although these devices
are relatively safe, inadvertent patient injury may occur with their
use, such as oral cavity burns. We describe a simple surgical technique
that reduces the risk of oral burns during electrocautery tonsillectomy
and review additional safety considerations.
Introduction
Electrocautery tonsillectomy continues to be the most common
technique used to remove hypertrophic tonsils despite the introduction
of new technologies such as the laser, the microdebrider, coblation, and
the harmonic scalpel. Decreased intraoperative bleeding rates, improved
operative times, and overall cost savings compared to those of
"cold knife" techniques have contributed to this trend.
Electrocautery devices are widely available and commonly used for
many routine head and neck surgical procedures. While these devices are
relatively safe, inadvertent patient injury may occur due to the
malfunction or improper use of surgical devices, errors in surgical
technique, carelessness of operating room personnel, or a combination of
these factors. Multiple accounts of inadvertent oral cavity burns during
electrocautery tonsillectomy have been documented in the medical
literature. It is likely that many more such injuries occur but are not
reported.
We present a simple surgical technique that greatly reduces the

risk of oral burns during electrocautery tonsillectomy and review


additional important considerations for safely performing this
procedure.
Pitfalls to avoid
A common error in the use of electrocautery devices is the
incomplete insertion of the insulated electrocautery tip into the
handpiece (figure 1). This may expose the patient's oral tissues to
the uninsulated portion of the electrode, thereby allowing arcing of the
electrical current and causing inadvertent burns. The surgeon or
assistant also may accidentally pull the tip loose from the handpiece
during cleaning.
Manufacturing defects in the electrode insulation, accidental use
of an unninsulated electrocautery tip, or direct contact with the
patient's tissues minor burn prevention or other conductive devices within the surgical
field may also contribute to injury.
Surgical technique
Most surgeons hold the electrocautery handpiece like a pencil,
using the thumb and index finger to manipulate the tip. By simply
sliding the middle finger of the operating hand between the handpiece
and oral commissure or buccal mucosa, the surgeon can create a physical
barrier and electrical insulator to decrease the risk of inadvertent
direct contact or arcing between the handpiece and the patient's
oral cavity (figure 2). This technique should likewise be employed with
handling of the tonsil tenaculum, because arcing from the electrocautery
tip to the tenaculum can occur and contribute to an unintentional oral
burn.

There is a slight learning curve involved in employing and


adjusting to this technique; however, the authors have practiced this
method for years and have taught it to otolaryngology residents with
consistent results. Employing this technique also serves as a
psychological reminder to the surgeon to employ basic safety principles
when using electrosurgical devices during head and neck surgery.
Discussion
The majority of tonsillectomies carried out during the last half of
the 20th century were performed with the "cold knife"
technique; that is, by employing a Dean or Fisher knife and tonsil snare
to remove the palatine tonsil from its fossa. Hemorrhage was then
controlled with direct pressure and resorbable suture. (1) However,
Krishna et al (2) and Eibling (3) report that the monopolar
electrocautery technique for tonsillectomy is now being practiced by the
majority of otolaryngologists in the United States. The reason for this
trend, according to the results of the Krishna survey, was a decrease in
intraoperative blood loss seen with the electrocautery technique.
[FIGURE 1 OMITTED]
O-Lee and Rowe performed a cost analysis comparing electrocautery
with the cold knife technique for adenotonsillectomy and demonstrated
overall decreased surgical times and an average variable cost savings of
19% in the electrocautery group. (4) Additionally, studies in the
current literature have demonstrated comparable postoperative hemorrhage
rates between electrocautery and cold steel tonsillectomy groups. (5,6)
While tonsillectomy-associated hemorrhage and pain are discussed
frequently in the medical literature, little discussion exists regarding

complications secondary to the use of electrocautery devices in the oral


cavity. In an excellent article discussing the fundamentals of
electrocautery devices, Zinder and Parker describe an incident of an
inadvertent oral commissure burn from a bipolar electrocautery handpiece
contacting the oral commissure during a routine tonsillectomy. (7)
In Smith and Smith's national survey of otolaryngologists
regarding electrosurgery complications, 267 of 324 (82%) complications
related to electrosurgical instruments were direct burns resulting from
unintentional contact between the active electrode and tissue or burns
resulting from the flow of electrical current through a metallic
retractor or instrument? These authors noted that four of the direct
burns during oral cavity surgery had required commissuroplasty.
[FIGURE 2 OMITTED]
Respondents to the Smith and Smith survey were also asked about the
complications that had occurred throughout their careers. Of the burns
reported, eight occurred because of a "leak of current" at the
connection between the Bovie handle and the tip. (8) These findings are
significant, and it is likely that many more such injuries occur but are
not reported.
Noteworthy to this discussion is the practice by some surgeons of
placing a cut piece of a red rubber catheter over the portion of the
electrocautery tip where electrical current could leak. (9) Commercially
available protective sheaths, such as the Safety Sleeve (Valleylab, a
division of Tyco Healthcare Group LP; Boulder, Colo.), are also
available and serve a similar protective function.
Routine use of these barriers could indeed prevent electrical

injury, but the added time and expense involved may be a deterrent to
their use in clinical practice. Conversely, our described technique of
electrocautery handpiece operation adds no extra time or cost to the
procedure and can be practiced routinely in any operative setting,
regardless of the availability of electrocautery accessories.
The technique we have described is simple and straightforward. It
is not difficult to learn, and continued practice makes it second nature
for the operating surgeon. This technique will decrease the risk of
inadvertent oral cavity burns during tonsillectomy and other surgeries
of the oral cavity by creating a physical barrier and electrical
insulator between the electrocautery handpiece and patient's oral
tissues.
We also suggest that as an adjunct to this technique, preoperative
and intraoperative inspection of the electrocautery handpiece and tip be
carried out by the operating surgeon and assistant, to ensure that the
tip is firmly seated in the handpiece. Additionally, using minimum power
settings, activating the handpiece only while in contact with the
patient, and avoiding close contact between the tip and metallic devices
within the mouth will help avoid unintentional injury. (7)
Adenotonsillectomy is one of the first surgical procedures an
otolaryngology resident learns. An inexperienced resident may become
focused on the tonsillar tissue and lose awareness of the entire
surgical field. Employing this technique helps new surgeons develop that
awareness, which translates to increased safety for the patient and
decreased risk of complications. We recommend the teaching of the
described tonsillectomy technique to otolaryngology residents and

encourage experienced otolaryngologists to employ it, as well.


References
(1.) Bailey BJ. Tonsillectomy. In: Bailey BJ, Calhoun KH, eds.
Atlas of Head and Neck Surgery--Otolaryngology. 2nd ed. Philadelphia:
Lippincott Williams and Wilkins; 2001:858-9.
(2.) Krishna P, LaPage MJ, Hughes LF, Lin SY. Current practice
patterns in tonsillectomy and perioperative care. Int J Pediatr
Otorhinolaryngol 2004;68(6):779-84.
(3.) Eibling DE. Tonsillectomy. In: Myers EN, ed. Operative
Otolaryngology Head and Neck Surgery. Philadelphia: W.B. Saunders
Company; 1997:186-98.
(4.) O-Lee TJ, Rowe M. Electrocautery versus cold knife technique
adenotonsillectomy: A cost analysis. Otolaryngol Head Neck Surg
2004;131(5):723-6.
(5.) Walker P, Gillies D. Post-tonsillectomy hemorrhage rates: Are
they technique-dependent? Otolaryngol Head Neck Surg 2007;136(4
Suppl):S27-31.
(6.) Wei JL, Beatty CW, Gustafson RO. Evaluation of
posttonsillectomy hemorrhage and risk factors. Otolaryngol Head Neck
Surg 2000;123(3):229-35.
(7.) Zinder DJ, Parker GS. Electrocauteryburns and operator
ignorance. Otolaryngol Head Neck Surg 1996; 115 (1): 145-9.
(8.) Smith TL, Smith JM. Electrosurgery in otolaryngology-head and
neck surgery: Principles, advances, and complications. Laryngoscope
2001;111(5):769-80.
(9.) Nichter LS, Goldstein LJ, Bush AM, et al. A simple method for

preventing misplaced electrocauterization. Plast Reconstr Surg


1987;80(2):307.
Thomas R. Lowry, MD, FACS; Jonathon R. Workman, MD, FACS
From the Marshfield Clinic, Eau Clair, Wisc. (Dr. Lowry) and
Eastern Carolina ENT Head and Neck Surgery, Greenville, N.C. (Dr.
Workman).
Corresponding author: Thomas R. Lowry, MD, Marshfield Clinic, 3800
Craig Rd., Eau Claire, WI 54701. Phone: (715) 858-4747; fax: (715)
858-4505; e-mail: lowry.thomas@marshfieldclinic.org