CASE STUDY

Case Study: Tonsil Removal



Case Study: Tonsil Removal

Patient History

A 4-year-old patient Mary presented with a history of recurrent streptococcal tonsillitis over the past 2 years and a longstanding history of nasal obstruction and breathing via her mouth. She was otherwise in excellent health but was concerned about this problem because she was a runner. By the time she presented for evaluation, the bouts of tonsillitis would occur within a few weeks of completing treatment with antibiotics. She did not smoke, take any other medication, or undergo any previous surgery.

Question 1a: Identify two of mary's needs which are being met.

Question 1b: Identify two of needs which are not being met.

Clinically, the patient met the indications for tonsillectomy. She also had significant nasal obstruction, for which septoplasty and reduction of the turbinates were recommended. During the preoperative discussion, information regarding Coblation® bipolar radiofrequency technology was provided, and it was agreed to use this equipment for the total removal of the tonsils and for the reduction of the turbinates. Subtotal removal of the tonsils using Coblation was discussed; however, because of the number of recurrent infections, (Montgomery 1996) it was recommended that the patient undergo total removal of the tonsils.

After the induction of general anesthesia, the nasal area was injected with a local anesthetic agent and packed with 4% cocaine. The tonsils were removed using the Coblation tonsil wand at a setting of 6. Bleeding was controlled with the radiofrequency coagulation function. After the tonsillectomy, the patient underwent septoplasty; the Coblation ReFlex Ultra 45 Wand® was used for the inferior turbinates at a setting of 6. On the left side, which had the larger turbinate, 4 passes of 10 seconds were made; on the right side, 3 sites were treated.

By the second day postoperatively, the patient developed nausea from the narcotic pain medication and was switched to only acetaminophen for discomfort (Lee 2008). The procedure was performed 6 months earlier; since then, she has been free of tonsillar infections, is breathing well through the nose, and continues her running.

Question 2: Give a detailed description of suitable ways to meet mary's needs.

As surgeons, we are always looking for ways to help our patients through surgery safely, with as little morbidity as possible. Electrocautery requires high temperatures (300ºC) for both cutting and coagulation functions, which causes damage to the tissue of the tonsil bed. (Kramer 2005)

Coblation, a bipolar radiofrequency process, is delivered at low temperatures (40ºC to 60ºC) in a plasma field, and the bonds between cells are broken down, allowing tissue to be removed or destroyed. The Coblation Wand can be used to “shave” the tissue of the tonsils to the level of the capsule or as an instrument for total removal of the tonsils, as in this case.

The ideal instrument for the removal of the tonsils would cut with minimal damage to surrounding tissues, effectively control bleeding points, and allow suctioning in the oropharynx. The bipolar Coblation radiofrequency Wand meets these criteria and is effective technology for tonsillectomy (Nsow ...