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Pediatric tonsillectomy with bipolar electrosurgical scissors
Original Contributions Pediatric Tonsillectomy With Bipolar Electrosurgical Scissors Glenn Isaacson, MD, and Wasyl Szeremeta, MD Purpose: The optimal technique for pediatric tonsillectomy remains a hotly debated topic. The speed and superior hemostatic properties of electrosurgical dissection must be weighed against the greater tissue preservation and more rapid healing of cold dissection techniques. Materials and Methods: We have used a new surgical device, bipolar electrosurgical scissors, in 30 consecutive pediatric tonsillectomies. This instrument provides mechanical cutting with or without simultaneous bipolar electrocoagulation. Results: The average surgical time was 6 minutes. There was no intraoperative blood loss. There were no immediate or late post-tonsillectomy hemorrhages. All tonsillar fossae were completely healed at 2-week follow-up. Conclusion: Bipolar electrosurgical scissors provide the best properties of both cold dissection and electrosurgical tonsillectomy without increasing surgical time or cost. Copyright 0 1998 by W.B. Saunders Company
Despite 100 years of technical refinement, pediatric tonsillectomy remains a morbid procedure-l Immediate and delayed post-tonsillectomy hemorrhages still complicate 0.2% to 3% and 1% to 7% of procedures, respectively. Pain, dysphagia, and weight loss are nearly universal.2-4 Numerous publications describe variations on surgical technique and perioperative management attempting to address the shortcomings of tonsillectomy.5-7 Comparison of cold surgical and electrosurgical dissection has been a focus of debate in the last decade.3s8-13 Our practice is composed entirely of children. Our most common indication for tonsillectomy is obstructive sleep apnea, and more than a third of our patients are children under the age of 3 years. As such, minimizing surgical time and blood loss has been of importance From the Department of Otorhinolaryngology and Bronchoesoohaaoloav. Temole Universitv School of Medicine and Temple U%versity Children’s *Medical Center, Philadelphia, PA. Address reprint requests to Glenn Isaacson, MD, Department of Otorhinolaryngology and Bronchoesophagology, Temple University School of Medicine, 3400 N Broad St, Philadelphia, PA 19140. Copyright 0 1998 by W.B. Saunders Company 0196-0709/98/l 905-0007$8.00/0 American Journal of Otolatyngology,
to us and led to the use of electrosurgical tonsillectomy in nearly all of our cases. We, like several investigators,12*13 have observed delayed healing in children undergoing monopolar electrosurgical tonsillectomy. We have been searching for a technique that preserves the anterior tonsillar pillar and minimizes damage to the tonsillar fossae, yet does not increase surgical time or blood loss. Bipolar electrosurgical scissors for open surgical dissection were introduced in the US market in the spring of 1997. We have used this dissecting instrument for all of our tonsillectomies since November of that year. It has the capacity to divide tissue sharply or to combine sharp and electrosurgical effects simultaneously. We describe a technique of tonsillectomy using this new instrument and provide data on the outcomes of our first 30 cases. MATERIALS
AND
METHODS
Bipolar, electrosurgical scissors (Powerstar, Ethicon, Somerset, NJ) were used in 30 consecutive pediatric tonsillectomies. Stevens tenotomy, Mayo, and 7- and g-inch Metzenbaum scissors are currently available from the manufacturer (Fig 1). The 7-inch Metzenbaum variety has worked best for us.
Vol 19, No 5 (September-October),
1998: pp 291-295
291
ISAACSON
292
AND
SZEREMETA
Figl. Bipolar electrosurgical scissors. Note the lack insulation on the distal end the scissors blades.
In performing the tonsillectomy, the patient is orotracheally intubated and placed in the Rose position. The mouth is opened with an appropriately sized Crow-Davis gag, and a headlight is used for illumination. We have found neither loupe magnification nor an operating microscope helpful. The back surface of the T-inch Metzenbaum scissors is insulated with a strip of polyvinyl chloride electrical tape. The tonsil is grasped near its superior pole with a curved tenaculum and drawn medially, while the uvula is distracted superiorly by an assistant using a Yankauer suction tube (Fig ZA). With the tonsil on tension, the superior edge of the anterior pillar is incised with the scissors in electrified mode (Valley Lab electrosurgical unit, Boulder, CO) [bipolar power setting, 201 (Fig 2B). The anterior pillar mucosa is then incised from superior to inferior with the scissor in nonelectrified mode. A pocket is created by blunt dissection between the lateral tonsillar surface and the superior constrictor muscle (Fig 2C). Identified vessels are coagulated and then divided with the scissors in electrified mode. Dissection is carried to the inferior pole, dividing the posterior tonsillar pillar mucosa sharply (Fig 2D). The scissors are again set in electrified mode to slowly divide the inferior pole vessels and lymphoid tissue to complete the dissection. Minor bleeding during dissection can be controlled by using the tips of the scissors as a bipolar forceps on either side of the bleeding point. A monopolar suction cautery supplements bipolar coagulation as needed. The cutting edges of the scissors clean themselves of char each time the scissors are closed. The outer surface of the scissors should be cleaned with a moist sponge. Care should be taken to avoid touching the inside of the cheek or edge of the tongue with the back of the scissors, as a burn may result.
of of
Thirty children, aged 2 to 14 years, underwent tonsillectomy with or without adenoidectomy. The average operative time for tonsillar removal was 6 minutes, similar to that with monopolar electrosurgical technique. There were no immediate or delayed post-tonsillectomy hemorrhages in this group. All tonsillar fossae were mucosalized and free of granulation at the first postoperative visit, usually at 14 days after surgery.
DISCUSSION The best way to do a tonsillectomy is frequently discussed in the otolaryngology literature.14J5 Advocates of cold scissors dissection tonsillectomy have presented evidence that healing is more rapid and postoperative pain less than with other techniques. This is thought to result from maximum preservation of oral mucosa and minimum damage to tissues when mechanical rather than thermal effects are used for dissection. Post-tonsillectomy pain and bleeding risk generally continue until the tonsillar fossae are fully mucosalized. Epithelial ingrowth from the cut edges of the anterior and posterior tonsillar pillars provides much of this remucosalization. Large tissue defects and thermal damage to the pillar mucosa can thus delay healing and increase the potential for discomfort and late complications. Electrosurgical instruments and lasers all achieve cutting and simultaneous hemostasis by sealing the blood vessel lumina by virtue of tissue heating.16J7 Operative time and intraop-
PED
TONSILLECTOMY
WITH
BIPOLAR
SCISSORS
Fig 2. (A) The superior pole of the tonsil is grasped and pillar mucosa; (C) a pocket is created between the tonsillar dissection is carried to the inferior pole.
erative blood loss are minimized when such devices are used. This has great appeal to any surgeon, but it is particularly important when surgery involves very small children with obstructive sleep apnea. In this population, total operative time should be minimized because lengthy surgery leads to longer periods of tongue compression by the mouth gag, postoperative edema, and upper airway obstruction. Unfortunately, more of the anterior pillar is sacrificed by using electrosurgical and laser techniques because the dissection is done entirely under direct vision rather than permitting blunt dissection beneath an intact anterior pillar, as is the case with cold scissors dissection. Dissatisfaction with monopolar electrosurgery led Andrea l8 to advocate the use of bipolar bayonet forceps for tonsillectomy. He and others who have tried his technique claim decreased morbidity and improved tissue effects.8110 Bipolar administration of radiofre-
drawn medially; (B) an incision is made in the capsule and the superior constrictor muscle;
anterior and (D)
quency currents results in less electrical energy being leaked to distant tissues and, thus, more precise coagulation. In addition, bipolar coagulation is effective in the presence of blood or tissue fluids that tend to prematurely diffuse monopolar currents on their way from the active (handpiece) to the return (grounding pad) electrode .lg Bipolar tonsillectomy requires greater surgical time than monopolar tonsillectomy,zO in part because of the frequent need to clean char from the bayonet forceps. It would seem ideal to combine the blunt dissecting capacity and precise cutting of cold scissors with a technology that allows for coagulation of vessels before their division. Scissors capable of both mechanical cutting and electrocoagulation were developed in the early 1990s for use in laproscopic surgery. Bipolar and monopolar variations on such scissors have been compared. Bipolar electrosurgical scissors showed superior tissue effects in a rabbit model. Division of tissues was
294
similar with each instrument, but depth of tissue necrosis was less with bipolar scissors and the extent of injury was more predictable over a range of power densities.21 A patent was issued for bipolar electrosurgical scissors for open surgical dissection in 1994 (US patent no. 5,324,289). This device is unique in that a thin layer of hard, insulating plastic acts as one of the mechanical cutting surfaces. This plastic (Vyolex 10002, DuPont, Wilmington, DE), in combination with a Nylon screw, isolates the two blades of the scissors from one another. Thus, all electrical current flows through the small amount of tissue trapped between the blades of the scissors during cutting, producing high current density just where it is needed. In addition, because the layer of plastic fused to one blade of the scissors is harder than steel, it continuously cleans and sharpens the opposite blade. This prevents the accumulation of char that slows the use of most bipolar instruments and, thus, allows the scissors to be used many times. Ethicon, Inc (Somerset, NJ) marketed four commercial products based on this patent under the brand name Powerstar in the spring of 1997. These products included a Stevens tenotomy and a Mayo, y-inch, and g-inch Metzenbaum scissors. The manufacturer claims that these scissors may be sterilized and reused up to 30 times. If this proves true, the cost per use of these scissors is similar to disposable monopolar electrodes. Our initial experience with bipolar electrosurgical scissors has been very favorable. The ability to divide tissues either mechanically or with the combination of electrocoagulation and mechanical force is ideal for working in a vascular bed. The tips of the scissors can be used for blunt dissection of loose connective tissue and, when electrified, can be held in an open position to act as a bipolar coagulator before dividing a vessel. On the negative side, the T-inch Metzenbaum scissors are somewhat awkward for dissecting the lower tonsillar pole. Care must be taken to protect the buccal mucosa and the edge of the tongue from the back edge of the scissors. The terminal 3 cm of the upper jaw of these scissors is not insulated. As a result, current can flow through moist oral tissues from the lower blade to this
ISAACSON
AND
SZEREMETA
noninsulated back edge of the upper blade and cause a superficial burn. We now insulate this surface with a small piece of plastic tape to minimize the risk. Metzenbaum scissors that are insulated more completely or other scissors designs (ie, Lakeside or Knight) might prove superior for intraoral use. We have performed a pilot study employing commercially available bipolar electrosurgical scissors for pediatric tonsillectomy. This instrument appears to combine the best of cold scissor dissection and electrosurgical techniques, allowing rapid tonsillar removal with minimal bleeding and desirable tissue effects. The development of scissors specifically designed for intraoral use may improve the ease of use and safety of this new class of surgical tools. ADDENDUM As of June 1, 1998, we consecutive tonsillectomies cal scissors. There have been gical hemorrhages and only episodes. The manufacturer new scissors models with more refined tips.
have performed 209 by using electrosurgino immediate postsurfour delayed bleeding has released several better insulation and
REFERENCES 1. Linden BE, Gross CW, Long TE, et al: Morbidity in pediatric tonsillectomy. Laryngoscope 100:120-124, 1990 2. Colclasure JB, Graham SS: Complications of outpatient tonsillectomy and adenoidectomy: A review of 3,340 cases. Ear Nose Throat J 69:155-160,199O 3. Szeremeta W, Novelly NJ, Benninger M: Postoperative bleeding in tonsillectomy patients. Ear Nose Throat J 75:373-376, 1996 4. Paradise JL: Tonsillectomy and adenoidectomy, in Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, vol 2 (ed 3). Philadelphia, PA, Saunders, 1996, pp 1054-1065 5. Oas RR, Bartels JP: KTP-532 laser tonsillectomy: A comparison with standard technique. Laryngoscope 100: 385-388, 1990 6. Cozzi LA, Megerian CA, Dugue C, et al: Pulmonary sequelae of intraparenchymal bismuth subgallate. Laryngoscope 102:597-599,1992 7. Rasgon BM, Cruz RM, Hilsinger RL, et al: Infiltration of epinephrine in tonsillectomy: A randomized, prospective, double-blind study. Laryngoscope 101:114-118,199l 8. Pang YT: Paediatric tonsillectomy: Bipolar electrodissection and dissection/snare compared. J Laryngol Otol 109:733-736,1995 9. Trent CS: Electrocautery versus epinephrine-injection. Ear Nose Throat J 72:520-522,1993 10. Brodsky L, Pizzuto M, Gendler J, et al: Microbipolar dissection vs. cold knife/suction cautery tonsillectomy in children: Preliminary results of a prospective study. Acta Otolaryngol (Stockh) Suppl523:256-258,1996
PED
TONSILLECTOMY
WITH
BIPOLAR
SCISSORS
11. Leach J, Manning S, Schaefer S: Comparison of two methods of tonsillectomy. Laryngoscope 103:619-622,1993 12. Wexler DB: Recovery after tonsillectomy: Electrodissection vs. sharp dissection techniques. Otolaryngol Head NeckSurg 114:576-581, 1996 13. Weimert TA, Babyak JW, Richter HJ: Electrodissection tonsillectomy. Arch Otolaryngol Head Neck Surg 116:186-188,199O 14. MacGregor FB, Albert DM, Bhattacharyya AK: Postoperative morbidity following paediatric tonsillectomy: A comparison of bipolar diathermy dissection and blunt dissection. Int J Pediatr Otorhinolaryngol31:1-6,1995 15. Neumann AM, Jr, Wiatrak BJ: Erbe constant voltage electrocautery versus conventional variable voltage electrocautery for tonsillectomy in children. Int J Pediatr Otorhinolaryngol40:35-40,1997
295
16. Sajjadian A, Isaacson G: Electrosurgery in the head and neck. Ann Otol Rhino1 Laryngol 107:254-261,1998 17. Tucker RD, Platz CE, Landas SK: Histologic characteristics of electrosurgical injuries. J Am Assoc Gynecol Laparosc 4:201-206,1997 18. Andrea M: Microsurgical bipolar cautery tonsillectomy. Laryngoscope 103:1177-1178,1993 19. Malis LI: Electrosurgery. J Neurosurg 85:970-975, 1996 20. Akkielah A, Kalan A, Kenyon GS: Diathermy tonsillectomy: Comparisons of morbidity following bipolar and monopolar microdissection needle excision. J Laryngol Otol 111:735-738,1997 21. Baggish MS, Tucker RD: Tissue actions of bipolar scissors compared with monopolar devices. Fertil Steril 63:422-426,1995
Despite 100 years of technical refinement, pediatric tonsillectomy remains a morbid procedure-l Immediate and delayed post-tonsillectomy hemorrhages still complicate 0.2% to 3% and 1% to 7% of procedures, respectively. Pain, dysphagia, and weight loss are nearly universal.2-4 Numerous publications describe variations on surgical technique and perioperative management attempting to address the shortcomings of tonsillectomy.5-7 Comparison of cold surgical and electrosurgical dissection has been a focus of debate in the last decade.3s8-13 Our practice is composed entirely of children. Our most common indication for tonsillectomy is obstructive sleep apnea, and more than a third of our patients are children under the age of 3 years. As such, minimizing surgical time and blood loss has been of importance From the Department of Otorhinolaryngology and Bronchoesoohaaoloav. Temole Universitv School of Medicine and Temple U%versity Children’s *Medical Center, Philadelphia, PA. Address reprint requests to Glenn Isaacson, MD, Department of Otorhinolaryngology and Bronchoesophagology, Temple University School of Medicine, 3400 N Broad St, Philadelphia, PA 19140. Copyright 0 1998 by W.B. Saunders Company 0196-0709/98/l 905-0007$8.00/0 American Journal of Otolatyngology,
to us and led to the use of electrosurgical tonsillectomy in nearly all of our cases. We, like several investigators,12*13 have observed delayed healing in children undergoing monopolar electrosurgical tonsillectomy. We have been searching for a technique that preserves the anterior tonsillar pillar and minimizes damage to the tonsillar fossae, yet does not increase surgical time or blood loss. Bipolar electrosurgical scissors for open surgical dissection were introduced in the US market in the spring of 1997. We have used this dissecting instrument for all of our tonsillectomies since November of that year. It has the capacity to divide tissue sharply or to combine sharp and electrosurgical effects simultaneously. We describe a technique of tonsillectomy using this new instrument and provide data on the outcomes of our first 30 cases. MATERIALS
AND
METHODS
Bipolar, electrosurgical scissors (Powerstar, Ethicon, Somerset, NJ) were used in 30 consecutive pediatric tonsillectomies. Stevens tenotomy, Mayo, and 7- and g-inch Metzenbaum scissors are currently available from the manufacturer (Fig 1). The 7-inch Metzenbaum variety has worked best for us.
Vol 19, No 5 (September-October),
1998: pp 291-295
291
ISAACSON
292
AND
SZEREMETA
Figl. Bipolar electrosurgical scissors. Note the lack insulation on the distal end the scissors blades.
In performing the tonsillectomy, the patient is orotracheally intubated and placed in the Rose position. The mouth is opened with an appropriately sized Crow-Davis gag, and a headlight is used for illumination. We have found neither loupe magnification nor an operating microscope helpful. The back surface of the T-inch Metzenbaum scissors is insulated with a strip of polyvinyl chloride electrical tape. The tonsil is grasped near its superior pole with a curved tenaculum and drawn medially, while the uvula is distracted superiorly by an assistant using a Yankauer suction tube (Fig ZA). With the tonsil on tension, the superior edge of the anterior pillar is incised with the scissors in electrified mode (Valley Lab electrosurgical unit, Boulder, CO) [bipolar power setting, 201 (Fig 2B). The anterior pillar mucosa is then incised from superior to inferior with the scissor in nonelectrified mode. A pocket is created by blunt dissection between the lateral tonsillar surface and the superior constrictor muscle (Fig 2C). Identified vessels are coagulated and then divided with the scissors in electrified mode. Dissection is carried to the inferior pole, dividing the posterior tonsillar pillar mucosa sharply (Fig 2D). The scissors are again set in electrified mode to slowly divide the inferior pole vessels and lymphoid tissue to complete the dissection. Minor bleeding during dissection can be controlled by using the tips of the scissors as a bipolar forceps on either side of the bleeding point. A monopolar suction cautery supplements bipolar coagulation as needed. The cutting edges of the scissors clean themselves of char each time the scissors are closed. The outer surface of the scissors should be cleaned with a moist sponge. Care should be taken to avoid touching the inside of the cheek or edge of the tongue with the back of the scissors, as a burn may result.
of of
Thirty children, aged 2 to 14 years, underwent tonsillectomy with or without adenoidectomy. The average operative time for tonsillar removal was 6 minutes, similar to that with monopolar electrosurgical technique. There were no immediate or delayed post-tonsillectomy hemorrhages in this group. All tonsillar fossae were mucosalized and free of granulation at the first postoperative visit, usually at 14 days after surgery.
DISCUSSION The best way to do a tonsillectomy is frequently discussed in the otolaryngology literature.14J5 Advocates of cold scissors dissection tonsillectomy have presented evidence that healing is more rapid and postoperative pain less than with other techniques. This is thought to result from maximum preservation of oral mucosa and minimum damage to tissues when mechanical rather than thermal effects are used for dissection. Post-tonsillectomy pain and bleeding risk generally continue until the tonsillar fossae are fully mucosalized. Epithelial ingrowth from the cut edges of the anterior and posterior tonsillar pillars provides much of this remucosalization. Large tissue defects and thermal damage to the pillar mucosa can thus delay healing and increase the potential for discomfort and late complications. Electrosurgical instruments and lasers all achieve cutting and simultaneous hemostasis by sealing the blood vessel lumina by virtue of tissue heating.16J7 Operative time and intraop-
PED
TONSILLECTOMY
WITH
BIPOLAR
SCISSORS
Fig 2. (A) The superior pole of the tonsil is grasped and pillar mucosa; (C) a pocket is created between the tonsillar dissection is carried to the inferior pole.
erative blood loss are minimized when such devices are used. This has great appeal to any surgeon, but it is particularly important when surgery involves very small children with obstructive sleep apnea. In this population, total operative time should be minimized because lengthy surgery leads to longer periods of tongue compression by the mouth gag, postoperative edema, and upper airway obstruction. Unfortunately, more of the anterior pillar is sacrificed by using electrosurgical and laser techniques because the dissection is done entirely under direct vision rather than permitting blunt dissection beneath an intact anterior pillar, as is the case with cold scissors dissection. Dissatisfaction with monopolar electrosurgery led Andrea l8 to advocate the use of bipolar bayonet forceps for tonsillectomy. He and others who have tried his technique claim decreased morbidity and improved tissue effects.8110 Bipolar administration of radiofre-
drawn medially; (B) an incision is made in the capsule and the superior constrictor muscle;
anterior and (D)
quency currents results in less electrical energy being leaked to distant tissues and, thus, more precise coagulation. In addition, bipolar coagulation is effective in the presence of blood or tissue fluids that tend to prematurely diffuse monopolar currents on their way from the active (handpiece) to the return (grounding pad) electrode .lg Bipolar tonsillectomy requires greater surgical time than monopolar tonsillectomy,zO in part because of the frequent need to clean char from the bayonet forceps. It would seem ideal to combine the blunt dissecting capacity and precise cutting of cold scissors with a technology that allows for coagulation of vessels before their division. Scissors capable of both mechanical cutting and electrocoagulation were developed in the early 1990s for use in laproscopic surgery. Bipolar and monopolar variations on such scissors have been compared. Bipolar electrosurgical scissors showed superior tissue effects in a rabbit model. Division of tissues was
294
similar with each instrument, but depth of tissue necrosis was less with bipolar scissors and the extent of injury was more predictable over a range of power densities.21 A patent was issued for bipolar electrosurgical scissors for open surgical dissection in 1994 (US patent no. 5,324,289). This device is unique in that a thin layer of hard, insulating plastic acts as one of the mechanical cutting surfaces. This plastic (Vyolex 10002, DuPont, Wilmington, DE), in combination with a Nylon screw, isolates the two blades of the scissors from one another. Thus, all electrical current flows through the small amount of tissue trapped between the blades of the scissors during cutting, producing high current density just where it is needed. In addition, because the layer of plastic fused to one blade of the scissors is harder than steel, it continuously cleans and sharpens the opposite blade. This prevents the accumulation of char that slows the use of most bipolar instruments and, thus, allows the scissors to be used many times. Ethicon, Inc (Somerset, NJ) marketed four commercial products based on this patent under the brand name Powerstar in the spring of 1997. These products included a Stevens tenotomy and a Mayo, y-inch, and g-inch Metzenbaum scissors. The manufacturer claims that these scissors may be sterilized and reused up to 30 times. If this proves true, the cost per use of these scissors is similar to disposable monopolar electrodes. Our initial experience with bipolar electrosurgical scissors has been very favorable. The ability to divide tissues either mechanically or with the combination of electrocoagulation and mechanical force is ideal for working in a vascular bed. The tips of the scissors can be used for blunt dissection of loose connective tissue and, when electrified, can be held in an open position to act as a bipolar coagulator before dividing a vessel. On the negative side, the T-inch Metzenbaum scissors are somewhat awkward for dissecting the lower tonsillar pole. Care must be taken to protect the buccal mucosa and the edge of the tongue from the back edge of the scissors. The terminal 3 cm of the upper jaw of these scissors is not insulated. As a result, current can flow through moist oral tissues from the lower blade to this
ISAACSON
AND
SZEREMETA
noninsulated back edge of the upper blade and cause a superficial burn. We now insulate this surface with a small piece of plastic tape to minimize the risk. Metzenbaum scissors that are insulated more completely or other scissors designs (ie, Lakeside or Knight) might prove superior for intraoral use. We have performed a pilot study employing commercially available bipolar electrosurgical scissors for pediatric tonsillectomy. This instrument appears to combine the best of cold scissor dissection and electrosurgical techniques, allowing rapid tonsillar removal with minimal bleeding and desirable tissue effects. The development of scissors specifically designed for intraoral use may improve the ease of use and safety of this new class of surgical tools. ADDENDUM As of June 1, 1998, we consecutive tonsillectomies cal scissors. There have been gical hemorrhages and only episodes. The manufacturer new scissors models with more refined tips.
have performed 209 by using electrosurgino immediate postsurfour delayed bleeding has released several better insulation and
REFERENCES 1. Linden BE, Gross CW, Long TE, et al: Morbidity in pediatric tonsillectomy. Laryngoscope 100:120-124, 1990 2. Colclasure JB, Graham SS: Complications of outpatient tonsillectomy and adenoidectomy: A review of 3,340 cases. Ear Nose Throat J 69:155-160,199O 3. Szeremeta W, Novelly NJ, Benninger M: Postoperative bleeding in tonsillectomy patients. Ear Nose Throat J 75:373-376, 1996 4. Paradise JL: Tonsillectomy and adenoidectomy, in Bluestone CD, Stool SE, Kenna MA (eds): Pediatric Otolaryngology, vol 2 (ed 3). Philadelphia, PA, Saunders, 1996, pp 1054-1065 5. Oas RR, Bartels JP: KTP-532 laser tonsillectomy: A comparison with standard technique. Laryngoscope 100: 385-388, 1990 6. Cozzi LA, Megerian CA, Dugue C, et al: Pulmonary sequelae of intraparenchymal bismuth subgallate. Laryngoscope 102:597-599,1992 7. Rasgon BM, Cruz RM, Hilsinger RL, et al: Infiltration of epinephrine in tonsillectomy: A randomized, prospective, double-blind study. Laryngoscope 101:114-118,199l 8. Pang YT: Paediatric tonsillectomy: Bipolar electrodissection and dissection/snare compared. J Laryngol Otol 109:733-736,1995 9. Trent CS: Electrocautery versus epinephrine-injection. Ear Nose Throat J 72:520-522,1993 10. Brodsky L, Pizzuto M, Gendler J, et al: Microbipolar dissection vs. cold knife/suction cautery tonsillectomy in children: Preliminary results of a prospective study. Acta Otolaryngol (Stockh) Suppl523:256-258,1996
PED
TONSILLECTOMY
WITH
BIPOLAR
SCISSORS
11. Leach J, Manning S, Schaefer S: Comparison of two methods of tonsillectomy. Laryngoscope 103:619-622,1993 12. Wexler DB: Recovery after tonsillectomy: Electrodissection vs. sharp dissection techniques. Otolaryngol Head NeckSurg 114:576-581, 1996 13. Weimert TA, Babyak JW, Richter HJ: Electrodissection tonsillectomy. Arch Otolaryngol Head Neck Surg 116:186-188,199O 14. MacGregor FB, Albert DM, Bhattacharyya AK: Postoperative morbidity following paediatric tonsillectomy: A comparison of bipolar diathermy dissection and blunt dissection. Int J Pediatr Otorhinolaryngol31:1-6,1995 15. Neumann AM, Jr, Wiatrak BJ: Erbe constant voltage electrocautery versus conventional variable voltage electrocautery for tonsillectomy in children. Int J Pediatr Otorhinolaryngol40:35-40,1997
295
16. Sajjadian A, Isaacson G: Electrosurgery in the head and neck. Ann Otol Rhino1 Laryngol 107:254-261,1998 17. Tucker RD, Platz CE, Landas SK: Histologic characteristics of electrosurgical injuries. J Am Assoc Gynecol Laparosc 4:201-206,1997 18. Andrea M: Microsurgical bipolar cautery tonsillectomy. Laryngoscope 103:1177-1178,1993 19. Malis LI: Electrosurgery. J Neurosurg 85:970-975, 1996 20. Akkielah A, Kalan A, Kenyon GS: Diathermy tonsillectomy: Comparisons of morbidity following bipolar and monopolar microdissection needle excision. J Laryngol Otol 111:735-738,1997 21. Baggish MS, Tucker RD: Tissue actions of bipolar scissors compared with monopolar devices. Fertil Steril 63:422-426,1995