Research - (2024) Volume 19, Issue 6

OUTCOMES OF RADIOFREQUENCY VERSUS ELECTROCAUTERY TONSILLECTOMY: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROL TRIALS

Keywords

Radiofrequency tonsillectomy. Monopolar electrocautery. Patient outcomes. Systematic review

Introduction

Recurrent bouts of acute tonsillitis lead to chronic tonsillitis. The palatine tonsils become inflamed when harmful bacteria like Streptococcus and Staphylococcus infect them. In otorhinolaryngology, chronic tonsillitis, recurrent tonsillitis, and tonsillar hypertrophy are common conditions. They can result in language, swallowing, and breathing problems if left untreated. Serious side effects such as nephritis and rheumatic heart disease can potentially result from recurrent inflammation [1].

Both surgical and non-surgical approaches can be used to treat tonsillitis; however, surgical intervention is advised for patients who have per tonsillar abscess, severe tonsil hypertrophy, recurring acute inflammation, or inadequate non-surgical treatment [2]. The techniques used for tonsillectomy have progressively changed as medical research and technology have advanced. Coblation tonsillectomy (CT), electrocution tonsillectomy (ET), conventional cold dissection tonsillectomy (CCDT), ultrasonic scalpel tonsillectomy (UST), and thermal welding tonsillectomy (TWT) are currently the most often utilized techniques [3]. The two most promising surgical techniques now employed in clinical practice are ET and CT [4].

ET performs both cutting and haemostasis by heating tissue upon contact with the body through the high-frequency, high-voltage current produced by the energized electrode tip, which divides and coagulates the tissue [5].

Tonsillectomy is one of the most common surgical interventions for chronic tonsillitis, recurrent throat infections, and obstructive tonsillar hypertrophy. The methods include radiofrequency and electrocautery tonsillectomy. In radiofrequency tonsillectomy, lower temperatures are used to cause minimal injury to tissues, thus theoretically reducing postoperative pain and hastening the recovery process. On the other hand, electrocautery uses higher temperatures that may cause more serious thermal damage to the surrounding tissues, leading to increased discomfort and possibly delayed healing. Yet, despite the wide usage of both modes, there is still uncertainty in clinical practice as to which one affords better results with fewer complications. This systematic review will help to address these uncertainties by comparing the effectiveness, safety, and postoperative outcomes of radiofrequency tonsillectomy with electrocautery tonsillectomy. The review will consolidate the best available evidence to provide informed surgical decisions in an effort to optimize patient outcomes and minimize postoperative morbidity.

The main objective of the present systematic review is to compare the postoperative outcomes after radiofrequency and electrocautery tonsillectomy. Additionally, intraoperative blood loss and the incidence of postoperative haemorrhage will be reviewed, given their critical significance to the safety and recovery of patients.

Methods

Search strategy

The PRISMA and GATHER criteria served as the foundation for the systematic review. To find papers examining the information currently available on the postoperative outcomes following radiofrequency and electrocautery tonsillectomy, a thorough search was conducted. SCOPUS, Web of Science, Cochrane, and PubMed were the four electronic databases that the reviewers looked at. We used computerized searches to find every abstract and title we could find, then uploaded them to Rayyan after eliminating duplicates. For a thorough examination, the whole texts of the research papers that met the requirements for inclusion based on their abstract or title were obtained. Two impartial reviewers examined discrepancies and judged whether the extracted publications were appropriate.

Study population-selection

The PICO (Population, Intervention, Comparison, and Outcome) factors were implemented as inclusion criteria for our review: (i) Population: Patients undergoing tonsillectomy, (ii) Intervention: Radiofrequency tonsillectomy, (iii) Comparator: Electrocautery tonsillectomy, (iv) Outcomes: Postoperative outcomes and complications.

Data extraction

Data from studies that satisfied the inclusion requirements were extracted by two objective reviewers using a predetermined and uniform methodology. The following information was retrieved and recorded: (i) First author (ii) Year of publication, (iii) Study design, (iv) Participants’ number, (v) Age, (vi) Gender, (vii) Adverse outcomes, (viii) Main outcomes.

Quality review

The Cochrane Risk of Bias Instrument [6] was used to conduct a critical appraisal of the identified RCTs. This tool evaluates the risk of bias in seven fields: arbitrary sequence generation, allocation secrecy, blinding of participants and employees, blinding of outcome evaluation, inadequate outcome data, selective reporting, and additional bias sources. The risk of bias in each of these domains was classified as low, unclear, or high.

Results

The specified search strategy yielded 206 publications (Figure 1). After removing duplicates (n = 93), 113 trials were evaluated based on title and abstract. Of these, 89 failed to satisfy eligibility criteria, leaving just 46 full-text articles for comprehensive review. A total of 4 satisfied the requirements for eligibility with evidence synthesis for analysis (Figure 1).

Figure 1.

Figure 2. Cochrane risk of bias assessment.

Sociodemographic and clinical outcomes

We included four studies with a total of 337 patients undergoing tonsillectomy (166 in the radiofrequency group and 171 in the electrocautery group) and more than half of them 197 (58.5%) were males. Regarding the study designs, all of the included studies were prospective RCTs [8-11]. Two studies were conducted in the USA [8, 11], one in Turkey [9], and one in Thailand [10].

Key findings indicate that radiofrequency ablation and monopolar electrocautery are no different in terms of overall complications, daily pain scores, or narcotic use [8-11]. Radiofrequency tonsillectomy does seem to result in less intraoperative blood loss and shorter lengths of stay, contributing to reduced early postoperative pain intensity [8, 9]. Although surgical duration may be longer for radiofrequency tonsillectomy, the overall patient experience is described as less unpleasant compared to monopolar electrocautery. This might mean that the postoperative course after radiofrequency tonsillectomy is less eventful and better tolerated by the patients [10, 11].

The complications of radiofrequency ablation and monopolar electrocautery tonsillectomy are somewhat different. While radiofrequency ablation tends to have more bleeding incidents, there is a higher rate of overall adverse events and medication refills in the case of monopolar electrocautery [8]. However, significant intraoperative bleeding with either technique is infrequent [9]. Postoperative haemorrhage occurred in a small percentage of patients, slightly more in the monopolar electrocautery group compared to radiofrequency ablation [10]. Despite these divergences in some of the complications, no statistically significant differences in postoperative discomfort were found between the two techniques [11].

Discussion

Key findings are that radiofrequency tonsillectomy, though slightly longer in duration, offers significant advantages in terms of reduced intraoperative blood loss and shorter hospital stays. This adds to a better patient experience with less discomfort and possibly quicker recovery times. Data also suggest that radiofrequency tonsillectomy may reduce the intensity of early postoperative pain, further supporting its place as a less invasive alternative to traditional monopolar electrocautery.

According to a prior meta-analysis by Nunez et al., large, carefully planned randomized studies are required to ascertain if radiofrequency ablation tonsillectomy is superior to other methods or not [12]. Due to its potential to decrease intraoperative blood loss and shorten operating times, electrocautery is a common surgical technique [13, 14]. However, this procedure necessitates a significant amount of heat release at temperatures between 400 and 600 degrees Celsius, which could lead to excruciating postoperative discomfort and a protracted recuperation period [13]. As opposed to electro cauterization, tonsillectomy utilizing radiofrequency radiation uses radiofrequency energy in the 0.01–300 MHz range, which produces less heat. Additionally, the temperature is significantly lower, ranging from 40 to 70 degrees Celsius, which lowers the possibility of harming surrounding tissues and the intensity of postoperative discomfort [15].

This review reported that the complications of radiofrequency ablation and monopolar electrocautery tonsillectomy are somewhat different. While radiofrequency ablation tends to have more bleeding incidents, there is a higher rate of overall adverse events and medication refills in the case of monopolar electrocautery. However, significant intraoperative bleeding with either technique is infrequent. Postoperative haemorrhage occurred in a small percentage of patients, slightly more in the monopolar electrocautery group compared to radiofrequency ablation. Despite these divergences in some of the complications, no statistically significant differences in postoperative discomfort were found between the two techniques. Cai et al. found that there has been no statistical difference in the operation time between coblation tonsillectomy and electrocautery tonsillectomy. However, intraoperative blood loss was significantly lower in cases of coblation tonsillectomy compared to electrocautery tonsillectomy. Even though postoperative pain was lower for the group that underwent coblation tonsillectomy, the difference was not statistically significant. This also constitutes a faster return to normal diet after surgery, although reaching statistical significance [16].

It was remarked in the review that radiofrequency tonsillectomy would be ideal for patients with a risk of postoperative discomfort and prolongation of recovery due to the minimal adverse events, shortened lengths of stay, and intraoperative blood loss associated with it. This is highly advantageous for paediatric or high-risk patients. The higher potential for postoperative bleeding with radiofrequency tonsillectomy requires close monitoring and education of the patient. Monopolar electrocautery was as effective, mainly for reducing the time of surgery, comparing pain and effectiveness. The surgical approach tailored to the need optimizes each patient's outcome and satisfaction.

Strengths

The strengths are that this review combined data from several prospective randomized controlled trials, adding to the reliability and validity of the results. A direct comparison of radiofrequency versus monopolar electrocautery tonsillectomy across different populations enables a comprehensive overview of clinical outcomes with regard to complications, recovery times, and patient experiences. The inclusion of intraoperative and postoperative metrics allows for a balanced evaluation of safety and efficacy, contributing to more informed surgical decision-making.

Limitations

Despite these strengths, there are several limitations to this review. Sample sizes in some studies are small, which may limit the generalization of results to larger populations. Moreover, variability in patient demographics, surgical techniques, and postoperative care across these studies introduces a potential for bias. The follow-up periods in some trials may be too short to capture late-onset complications, and subjective measures of pain perception and patient satisfaction may be influenced by individual differences. Lastly, the higher incidence of postoperative bleeding in radiofrequency tonsillectomy may merely reflect inconsistencies in surgical competence rather than true procedural flaws inherent to the procedure.

Conclusion

The radiofrequency versus monopolar electrocautery tonsillectomy comparison underlines some key differences in patient outcomes. Radiofrequency tonsillectomy presents advantages of minimal intraoperative blood loss, reduced hospital stays, and less postoperative discomfort, making the procedure more favourable to many patients. However, the increased risk of postoperative bleeding requires close monitoring and teaching. Monopolar electrocautery, although showing slightly higher overall rates of adverse events, is still a reliable and efficient technique with comparable pain outcomes. By weighing strengths against limitations, these techniques allow clinicians to tailor surgical approaches to best meet patient needs and to create a much-improved quality of care and recovery.

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