Paediatric tonsillectomy in a regional setting: a 5-year comparative review of coblation intracapsular and extracapsular techniques

Introduction

Tonsillectomy is the most common surgical procedure performed within paediatric otolaryngology, with approximately 50,000 cases per year in Australia (1-3). The Australian Society of Otolaryngology Head and Neck Surgery endorses United Kingdom-based guidelines regarding tonsillectomy indications, amongst which sleep-disordered breathing (SDB) and recurrent acute tonsillitis are most common (4).

Post-tonsillectomy haemorrhage (PTH) remains a potentially serious complication in the postoperative period. PTH is classically divided into primary (within 24 hours of surgery) and secondary (after 24 hours), with a peak incidence at operative days 7 to 10 (5,6). Prevalence of primary and secondary PTH has been reported between 0.2–2% and 3–9.4%, respectively, with variation driven by heterogeneity in patient demographics, clinical indication for surgery, and operative techniques (5-9).

Traditionally, tonsillectomy has been performed as an extracapsular tonsillectomy (ECT) whereby the palatine tonsil is completely dissected from the underlying pharyngeal muscles. However, renewed interest in intracapsular tonsillectomy (ICT) has emerged following a 2003 publication by Koltai et al., which demonstrated favourable postoperative outcomes (10). The rationale for an intracapsular approach is driven by smaller intra-tonsillar blood vessels and absent neuronal tissue, in theory leading to reduced bleeding and pain (11,12). This effective reduction in pain and PTH drives a reduction in peri-operative morbidity, including decreased length of admission, decreased rates of return to hospital, as well as faster return to normal diet and activity (12-15). Moreover, recent papers show that ICT has equivalent outcomes in addressing the primary indication for surgery compared to ECT (13,14).

ICT is performed with varying surgical techniques, including cold steel, microdebrider, laser, and coblation. Coblation involves passing a high-frequency electrical current through a conductive medium, typically saline, creating a plasma field capable of low-temperature tissue disintegration (15). Attempting to standardise reporting, Windfuhr and Werner [2013] proposed classifying ICT in two groups (16). A class 1 ICT is defined as removal of tonsillar tissue medial to the faucial pillars, resulting in a Brodsky size of 1. Alternatively, a class 2 ICT describes the removal of 90% of the tonsil tissue, by width from the medial to lateral pharyngeal wall.

Objectives

This multicentre Australian study aims to evaluate the safety of coblation ICT compared to ECT.

Methods

Reporting guideline

The study is reported according to the STROCSS reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-6/rc).

Design

Retrospective observational cohort study of electronic medical records.

Setting

The Ear, Nose, and Throat (ENT) Department of the Northern New South Wales Health District (NNSWHD) employs ECT and ICT for the surgical management of paediatric SDB and recurrent tonsillitis. Surgery is performed by otolaryngology consultants or registrars under direct supervision of a consultant. Included are two Otolaryngology centres: The Tweed Hospital and Lismore Base Hospital. Several smaller satellite hospitals (Murwillumbah District Hospital, Byron Central Hospital, Grafton Base Hospital, Ballina District Hospital, Nimbin Hospital, and Casino District Hospital) without otolaryngology services, which feed into the primary centres for cases of emergency review (i.e., PTH), were likewise reviewed to improve data accuracy. Data was collected over a 5-year period from January 2020 to December 2024.

Coded surgical data were reviewed for cases matching the following coding between the dates described: tonsillectomy with/without adenoidectomy [41789 and 41793], adenoidectomy with/without tonsillectomy [41801], arrest of haemorrhage following tonsillectomy [41797], and arrest of nasal haemorrhage [41656 and 41677]. Each case file was individually examined for the variables described below (see the “Statistics analysis” section). As no specific coding exists within Australia for ICT, cases were classified as such only if explicitly documented as ‘intracapsular’ or ‘tonsillotomy’ within the operation report itself.

Participants

Children aged 16 or younger who have undergone bilateral ICT or bilateral ECT with or without adenoidectomy, cautery of turbinates, and grommets. All ICT cases were conducted with EVAC 70 Xtra HP (Smith+Nephew, Watford, UK) coblation device, aiming to remove 90% of the palatine tonsil, consistent with a class 2 ICT (16). Extracapsular cases were undertaken with coblation EVAC 70 Xtra HP (Smith+Nephew), BiZact^TM (Medtronic, Minneapolis, MN, USA), monopolar diathermy, or bipolar diathermy. Indications for emergency tonsillectomy were excluded (16).

Variables

The variables collected included immediate post-procedure data (before discharge): primary PTH (within 24 hours of surgery) (n), return to the operating room (n), and length of hospital stay (days). Post-discharge variables included readmission within 4 weeks of the procedure (n), reason for readmission (categorical: pain, bleeding, infection, dehydration, other), date from the initial procedure (days), length of stay during readmission (days, calculated from operation start to time of discharge), secondary PTH (occurring >24 hours after surgery) (n), transfusion requirement during readmission (n) and return to the operating room (n). Rates of revision tonsillectomy (n) were assessed with a minimum follow-up period of 4 months after the study period. Additionally, routine patient demographics including age, sex, procedure indication, surgical method, and grade of operating surgeon were also recorded. Geographical classification was determined using the Australian Statistical Geography Standard (ASGS; 2021), which categorises areas from remoteness area (RA)1 (major cities) to RA5 (very remote) based on patient’s postcode of residence. All patients in this study resided in either RA1 (major cities) and RA2 (inner regional) areas, with a small minority from RA3 (outer regional) regions.

Data sources/measurement

Variables included are outlined in the “Statistical analysis” section. All data was collected from electronic medical records. Patient rurality grading and distance from hospital were obtained using the patient’s address.

Statistical analysis

Statistical analysis was performed using SPSS (by IBM) statistical software. Simple frequencies and percentages of the categorical variables were calculated and tabulated. For quantitative variables, means and standard deviations (SDs) were calculated. To find comparison of various categorical factors among two procedures (ECT and ICT), Chi-squared test and Fisher’s exact test (where expected cells in count were less than 5) were applied, and for continuous factors, Mann-Whitney U test was applied. Missing data were excluded from analysis. Multivariable logistic regression was conducted to calculate adjusted odds ratios (aORs) for the outcomes of readmission for bleeding and all-cause readmission. Adjustment variables included age, sex, procedure indication, and surgeon grade. Statistical significance was established at a P value of <0.05.

Ethics consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The project was reviewed by the Northern NSW Local Health District Research Office under a non-Human Research Ethics Committee pathway for low-risk projects and was deemed to be consistent with the principles and values outlined in the National Statement on Ethical Conduct in Human Research (2007, ethics approval No. QA530). It was therefore granted exemption from Human Research Ethics Committee approval in accordance with NSW Health policy for low-risk projects. Patient confidentiality was maintained by anonymising data and individual consent was waived.

Results

Demographics

The analyses included a total of 782 patients of which 71.7% (n=561) underwent an ECT and 28.3% (n=221) underwent ICT. Table 1 presents the baseline descriptive statistics for both ICT and ECT cohorts. Ages ranged from 1.37 to 15.96 years with a mean of 6.44 (SD, 3.32) years. The mean age was significantly higher in the ECT cohort (6.89±3.53 years) compared to ICT [5.32±2.71 years; mean difference, 1.57 years; 95% confidence interval (CI): 1.11–2.03; P<0.01]. The ICT cohort was comprised of 58.4%% male (n=129) compared to 56.0% (n=314) for ECT, P=0.54.

Regionality

Mean distance to hospital was not significantly different between ECT and ICT cohorts at 48.1 and 45.2 km, respectively. There was a statistically significant association between tonsillectomy technique and remoteness classification (P<0.01). ECT cases were more concentrated in major cities (RA1: 58.8%) and inner regional areas (RA2: 40.5%), while ICT cases were more evenly distributed between RA1 (46.6%) and RA2 (53.4%) (Table 1).

Surgical indication, technique, and grade of operating surgeon

The primary indication for ICT was SDB, accounting for 94.6% (n=207) of cases. Combined SDB with recurrent tonsillitis accounted for 5% (n=11). One additional case (0.4%) was classified as “other”—a child originally scheduled for ICT whose procedure was brought forward after presenting with a fish bone lodged in the tonsil. In the ECT group, indications included SDB (62.4%, n=350), SDB with recurrent tonsillitis (24.8%, n=139), recurrent tonsillitis (11.8%, n=66), histopathological assessment (0.7%, n=4), and other causes (0.4%, n=2). Comparing SDB as the primary indication, a significantly higher proportion of ICT cases were performed for this reason, with a risk difference of 32.2% (95% CI: 27.2–37.2%; P<0.01). Concurrent adenoidectomy was performed in 98.2% (n=217) of patients undergoing ICT compared to 93.8% (n=526) in the ECT group, a statistically significant risk difference of 4.4% (95% CI: 2.3–6.5%), P<0.05. All cases of ICT were performed using coblation. Among ECT cases, coblation was used in 52.2% (n=293), BiZact in 27.6% (n=155), bipolar in 15.3% (n=86), and monopolar in 4.8% (n=27). The proportion of cases performed with coblation was therefore 47.8% higher in the ICT cohort, risk difference 47.8% (95% CI: 43.6–51.9%), P<0.01. Consultant-led operating was 41.0% (n=230) in the ECT cohort and 32.1% (n=71) in the ICT cohort, with a risk difference of 8.9% (95% CI: 1.5–16.3%), P=0.02. These results are summarised in Table 2.

Length of stay

The mean length of stay was significantly higher for ECT (0.95±0.42 days) as compared to ICT (0.54±0.53 days; mean difference, 0.41 days; 95% CI: 0.33–0.49; P<0.01). Within the ECT group, 8.6% (n=48) of cases were day surgery compared to 47.1% (n=104) undergoing ICT, with a risk difference of 38.5% (95% CI: 31.5–45.5%), P<0.01.

Postoperative haemorrhage & readmission rates

Table 3 displays that all-cause readmission rates were significantly lower for ICT as compared to ECT (aOR =0.25; CI: 0.11–0.56; P<0.01). There were no primary PTH events within the population studied. Rates of secondary PTH were also significantly lower for ICT as compared to ECT (aOR =0.29; 95% CI: 0.11–0.76; P<0.01). Within ECT, 1.2% (n=7) required return to theatre for arrest of haemorrhage. No patients undergoing ICT required return to theatre. One patient in the ECT cohort required a single-unit blood transfusion. No patients in the ICT required blood transfusion. The mean day for secondary bleeds was not significantly different between ICT (7.2 days, n=5) and ECT (6.2 days, n=43), P=0.76. A complete display for all haemorrhagic events by day and frequency is shown in Figure 1.

Figure 1 Frequency of and distribution of PTH by surgical technique. ECT, extracapsular tonsillectomy; ICT, intracapsular tonsillectomy; PTH, post-tonsillectomy haemorrhage.

Within the study period, three patients who initially underwent ICT required revision tonsillectomy for tonsillar regrowth. The mean age at time of index surgery was 3.31±1.37, with a mean interval to revision ECT of 1.75±0.50 years. Revision tonsillectomy was undertaken with BiZact for two patients and bipolar diathermy in one.

Postoperative haemorrhage by surgical technique

Among patients undergoing ECT, the highest secondary haemorrhage rate was observed with coblation (9.6%; n=28/293), followed by bipolar diathermy (9.3%; n=8/86) and BiZact (4.5%; n=7/155). Monopolar cautery was not associated with any recorded postoperative bleeding in this cohort. A complete comparison of haemorrhage rates across modalities is presented in Table 4. In contrast, coblation ICT demonstrated a lower secondary haemorrhage rate of 2.3% (n=5/221), with no patients requiring return to theatre for haemorrhage control. Comparisons between purely coblation cases demonstrated a risk difference of 7.3% (95% CI: 3.4–11.2%, P<0.01) in favour of the ICT technique.

Discussion

Key findings

This is the second largest Australian study in the current literature reviewing the safety of ICT as compared to ECT (17,18). Overall rates of readmission were lower for ICT as compared to ECT. Moreover, rates of secondary PTH and return to theatre for arrest of haemorrhage events in patients undergoing ICT were lower as compared to ECT. Patients undergoing ICT had shorter length of stay in hospital as compared to ECT.

Comparison with relevant literature

Coblation ICT has gained increased adoption amongst practicing otolaryngologists, favoured for its reported reduction in several key postoperative morbidity indicators. Chiefly amongst these benefits is a reduction in PTH. A 2022 meta-analysis by Sedgwick et al. (11 studies; n=6,039) demonstrated significantly lower readmission rates for postoperative haemorrhage following ICT compared with ECT (risk ratio =0.36; P=0.01), corresponding to rates of 1.6% and 5.2%, respectively (19). Return-to-theatre rates were also lower for ICT (0.46% vs. 1.36%). Notably, all ICT procedures in that analysis were performed using coblation, consistent with the present study. Further contemporary papers support these findings. Powell et al. (UK, n=5,525) reported 1.2% readmissions and 0.2% return-to-theatre rates after coblation ICT (20), while Amin et al. (n=1,257) observed 0.5% secondary bleeding with no reoperations (21).

Australian data by Attard et al. (n=608) showed secondary PTH rates of 1.8% for ICT and 8.3% for ECT (18). Patient demographics, age, and sex were comparable to the present study. There was one primary PTH event within the ECT cohort. Indications for surgery were not as transparent as in the present study. Similarly, Loh et al. reviewed 12,275 patients in their extended data set comparing ECT to ICT (17). Rates of PTH were reported as 1.7% and 4.1% for the ICT and ECT cohorts, respectively, P<0.001. In this same paper, a refined cohort of 3,319 patients had demographic data available, including age and surgical indication, with proportions comparable to the present study. This refined cohort had secondary PTH rates of 6.4% for ECT and 1% for ICT.

In the current study, no primary PTH occurred in either cohort. Secondary PTH requiring admission occurred in 2.3% of ICT cases vs. 7.7% of ECT cases, a 71% reduction (aOR =0.29; 95% CI: 0.11–0.76; P<0.01). No ICT patients required return to theatre for arrest of haemorrhage compared to 1.2% (n=7) in the ECT group; however, sample sizes precluded statistical analysis of this difference. Excluding admissions without visible haemorrhage as seen in prior Australian studies (Stammberger A1) yields adjusted bleed rates of 1.4% (n=3) and 6.7% (n=39), respectively (18). Nonetheless, these admissions reflect institutional practices prioritising observation, particularly given the regional setting and limited paediatric emergency observation capacity. This context may differ from that of metropolitan centres and could partly account for the higher readmission rates observed in this cohort.

The present study demonstrated that ICT was associated with materially lower healthcare utilisation than ECT. The postoperative length of stay was significantly shorter following ICT (0.54±0.53 days; mean difference, 0.41 days; 95% CI: 0.33–0.49; P<0.01), reflecting a 47.1% (n=104) day-case rate. Moreover, the risk of all-cause readmission was significantly reduced among ICT patients, with an aOR of 0.25 (95% CI: 0.11–0.56; P<0.01).

Operative technique remains a considerable determinant of postoperative haemorrhage rates, with heated techniques being considered higher risk (7,22-24). The national Prospective Tonsillectomy Audit demonstrated an overall PTH rate of 3.5% with a return-to-theatre rate of 1% (7). Coblation tonsillectomy has reported secondary PTH rates ranging from 3.4% and 13.3% while BiZact shows rates between 2.48% and 5.9% (7,22-27). Within the current study, patients undergoing coblation ECT experienced the highest rates of both secondary PTH and return to theatre (Table 4). Comparing coblation cases only, secondary PTH occurred in 9.6% of ECT patients vs. 2.3% of ICT patients (aOR =4.30; 95% CI: 1.55–11.6; P<0.01), favouring ICT. BiZact ECT (4.5%, n=7) had rates of PTH and return to theatre lower than coblation ECT.

Tonsillar regrowth following ICT remains an area for investigation. The UK retrospective review by Powell et al. with 5,437 patients demonstrated a 2.2% revision tonsillectomy rate at 5 years from index surgery (20). Amin et al. reported revision surgery rates of 2.6% over their 7-year follow-up (21). The Australian study by Attard et al. demonstrated a revision rate of 2.4% (18). A Swedish study by Odhagen et al. with 27,535 patients demonstrated revision surgery rates of 3.9% for the ICT cohort (28). Within the present study’s timeframe, 1.4% (n=3) patients underwent revision tonsillectomy, a similar result to the UK study by Powell et al. at the 2-year mark (20). The mean interval to revision ECT was 1.75±0.50 years; however, interpretation is limited as follow-up duration was not predefined in the study design.

Limitations

As this was a retrospective study, the accuracy of the data depended on the precision and consistency of clinical coding, the operating surgeon’s documentation, and data collection, introducing the potential for misclassification bias at multiple levels. Although it is possible that some patients re-presented to hospitals outside those included in the study, this is considered unlikely given established referral pathways and substantial catchment distances. Furthermore, all post-tonsillectomy bleeds in Northern NSW are diverted to two centres, and additional hospitals were audited (see the “Variables” section), making it likely that any missed data would have only a minimal impact on the recorded outcomes. Additionally, it was not possible to verify whether 90% of the tonsil was removed, as per institutional preference. Uncertainty in this regard may influence subsequent rates of tonsillar regrowth, postoperative bleeding, and pain. Procedure selection (i.e., ECT vs. ICT) was undertaken in a non-randomised fashion. Institutional advocacy for ICT regarding patients in more regional locations may have introduced bias in patient/parental decision-making. Furthermore, surgeon preference for overnight admission vs. day surgery was not recorded. Therefore, a causal relationship between surgical technique and the need for overnight admission cannot be established. Nevertheless, the observed differences in length of stay reflect tangible patient and healthcare economic benefits, without added risk in the present cohort. Prospective follow-up at defined intervals was not established as part of the study design, thus data on the clinical efficacy of the treatment, as well as tonsillar regrowth, cannot be used for interpretation.

Conclusions

In conclusion, coblation ICT demonstrates lower rates of secondary PTH and return to theatre for arrest of bleeding compared to ECT. While variations in patient demographics, surgical indications, and institutional practices may influence specific outcomes, the findings of this study are consistent with broader literature. The study highlights the need for further investigation into long-term outcomes, such as tonsillar regrowth requiring revision surgery rates and efficacy of ICT for patients with recurrent tonsillitis. Overall, this study supports the adoption of coblation ICT as a safe alternative to traditional ECT in paediatric patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROCSS reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-6/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-6/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-6/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-6/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The project was reviewed by the Northern NSW Local Health District Research Office under a non-Human Research Ethics Committee pathway for low-risk projects and was deemed to be consistent with the principles and values outlined in the National Statement on Ethical Conduct in Human Research (2007, ethics approval No. QA530). It was therefore granted exemption from Human Research Ethics Committee approval in accordance with NSW Health policy for low-risk projects. Patient confidentiality was maintained by anonymising data and individual consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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