The “Swiss-cheese Doppler-guided laser tonsillectomy”: a new safe cribriform approach to intracapsular tonsillectomy
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- Palmieri, B., Iannitti, T., Fistetto, G. et al. Lasers Med Sci (2013) 28: 865. doi:10.1007/s10103-012-1140-1
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Outpatient laser ablation of palatine tonsils is a very interesting procedure that has been recently introduced as a routine in head and neck surgery departments. The aim of this study was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium–aluminium–garnet (YAG) laser to remove up to 80 % of tonsillar tissue, as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place, thus avoiding any haemorrhagic complication and minimize pain. A total of 20 patients (men, n = 13; women, n = 7), aged between 6 and 63, were recruited for the procedure. They were affected by chronic hypertrophic tonsillitis with a recurrent fever and other symptoms that were related to oral inflammation. Among the 20 patients, no serious adverse events, including haemorrhage-related complications, were observed. Treatment was well tolerated, even in patients displaying an overall low pain threshold. No dropout or uncompleted procedure occurred in the present study. Minor complications included sore throat, moderate oedema, mild acute pharynx inflammation, slight peritonsillar exudate and local burning. The postoperative pain, measured by Scott–Huskisson visual analogue scale, was between 5 and 40 mm and was easily counteracted by means of external ice packages and nonsteroidal anti-inflammatory drugs, according to the individual patient’s need. During the 12–36-month follow-up patients showed improved symptoms (n = 7) and complete recovery (n = 13). A relapse episode was observed in two patients. This study supports fibre optic laser neodymium-YAG tonsil surgery, named “cribriform intracapsular tonsillectomy” or “Swiss-cheese laser tonsillectomy”, as an effective alternative to the traditional cold knife approach or electrosurgery. This approach could become the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost–benefit ratio, the precise targeting of the beam across the affected tissues and the short- and long-term recovery.
KeywordsNeodymium-YAG laserTonsilTonsillectomySurgeryHead and neckInflammationPain
Outpatient laser ablation of palatine tonsils is a very interesting procedure that has been recently introduced as a routine in head and neck surgery departments [2, 7, 8]. The traditional technique of “cold” dissection was introduced about 100 years ago . Since then, many different techniques have been introduced to speed up the operation, keep intraoperative bleeding to a minimum and reduce postoperative morbidity. In Krespi and Ling’s  case series, laser tonsillar tissue vaporization under local anaesthesia is successfully reported in 96 % of patients during a 4-year follow-up period. On the other hand, general anaesthesia is required as a routine procedure for laser tonsillotomy or tonsillectomy, in children affected by chronic inflammation or sleep apnoea. According to some authors [2, 5, 8], during a single or multiple 15-min sessions, it is possible to remove the infected tonsillar crypts, leaving in place the capsule as well as almost 30 % of the deep tonsillar tissue. In adults, palatine tonsillectomy, with capsule excision for chronic recurrent tonsillitis, is also a classic technique requiring general anaesthesia with a risk of complications and postoperative pain. Andrews and Latif  described a local anaesthesia modification of Krespi and Ling’s  technique using a 40-W CO2 laser emitting focused laser energy through a small-sized handpiece with success in 74 % of cases with very low pain and complication rate. Sedlmaier et al.  reported positive results in 183 children operated with 812 nm 13 W infrared laser diode on an outpatient basis. No bleeding after the procedure was observed. Reichel et al.  compared 64 children with recurrent tonsillitis, who had undergone total blunt dissection tonsillectomy and 49 children with tonsillar hyperplasia without tonsillitis, who had undergone partial tonsillectomy with CO2 laser. This study has shown that tonsillotomy with CO2 laser technique is an effective surgical procedure with a long-lasting effect in patients with tonsillar hyperplasia. The benefits over conventional tonsillectomy are a lower risk for postoperative haemorrhage, reduced postoperative morbidity and accelerated recovery. Therefore, the procedure should be recommended for infected tonsils and might be an option in some patients with mild symptoms of recurrent tonsillitis. Huber et al.  described the use of argon laser needle delivery in tonsil hyperplasia surgical treatment in 15 children in comparison with historical CO2 laser approach. No haemorrhage was reported, oral food intake and swallowing were normal and postoperative pain was low especially in the third postoperative day favouring argon laser treatment.
Following tonsillectomy, immediate hospital readmission is mandatory in case of secondary bleeding, and an intensive care unit should intensively take care of the patient and, potentially, radiological embolization of the vascular bleeding network might be a lifesaving choice . Positive results have also been previously reported by Ericsson et al.  who compared the effects of partial tonsil resection using a radiofrequency technique in 92 children with total tonsillectomy. A follow-up after 1 and 3 years showed that removing only the protruding parts of the tonsils produces the same beneficial long-term effect on recurrent throat infections, if compared to total tonsillectomy. A further study compared the long-term effects of intracapsular partial tonsillectomy using CO2 laser technique and traditional blunt dissection tonsillectomy in 41 children aged between 9 and 15 (n (CO2 laser) = 21); n (traditional blunt dissection tonsillectomy) = 20) . Six years after the procedure, they were asked to answer ten questions about the results of the procedure. The findings from this study showed that partial tonsillectomy represents a reliable method with the same positive long-term effects of traditional treatment.
The aim of this article was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium–aluminium–garnet (YAG) laser to remove up to 80 % of tonsillar tissue as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place avoiding any haemorrhagic complication and pain.
Materials and methods
Summary of study results
Postoperative pain (VAS, mm) measured in the 7 days following the first session (medication used)
24 months/Improved symptoms
Moderate sore throat
18 months/Complete recovery
Moderate burning and local swelling persisting for 24 h
36 months/Complete recovery
16 months/Improved symptoms
Relapsing acute tonsillitis
21 months/Complete recovery
Tonsil remnants with infections
24 months/Complete recovery
Tonsillar hypertrophy and infections
16 months/Complete recovery
Moderate burning persisting for 48 h
40 (Diclofenac 100 mg capsules [2 times/day for 3 days; IBSA, Lugano, Switzerland])
21 months/Complete recovery
Relapsing tonsillitis and tonsillar hypertrophy
30 (Naprosyn 750 mg capsules, [2 times/day for 3 days; Recordati, Italy])
20 months/Complete recovery
Moderate pain and dysphagia
24 months /Complete recovery
Pyogenic tonsil remnants
Pain and scanty blood spots
40 (Tranex, 500 mg/5 ml ampoules [2 times/day for 1 day; Malesci Istituto Farmacobiologico, Bagno a Ripoli, Italy], Contramal 100 mg capsules [1/day for a day; Formenti, Milan, Italy])
20 months/Complete recovery
Tonsillar hypertrophy and relapsing tonsillitis
Burning and pruritus
18 months/ Complete recovery
Relapsing tonsillitis and laryngitis
Moderate discomfort and dryness
15 (Ephynal 300 mg capsules [3 times/day for 2 weeks; Abiogen Pharma, Pisa, Italy] and ice)
15 months/Improved symptoms
Post-viral tonsillar hypertrophy
19 months/ Improved symptoms
Moderate discomfort and cough
12 months/Improved symptoms
Tonsillitis and tonsillar hypertrophy
30 (Toradol 30 mg/ml ampoules [1/day for 2 days; Rome, Italy])
18 months/Complete recovery
Chronic fibrinous tonsillitis
Some transient dysphagia
14 months/Improved symptoms but one replapsing episode was observed
Acute relapsing tonsillitis
18 months/Complete recovery
Tonsillar hypertrophy and rheumatic fever
Slight oedema and swallowing burns
25 (local Xentafid 0.13 % [3 times/day for 5 days; Fidia Farmaceutici, Abano Terme, Italy] and ice)
24 months/Complete recovery
Waldeyer’s hypertrophy and tonsillar culture positive for Streptococcus viridians
Inflammation of the pharynx
35 (Augmentin 375 mg tablets [2 times/day for 3 days; GlaxoSmithKline, Verona, Italy])
24 months/Improved symptoms but one replapsing episode was observed
A maximum of three sessions was necessary (mean ± SEM; 1.55 ± 0.15). Among the 20 patients who participated in the present study, no major untoward effect, including haemorrhage-related complications, was observed. The vascular network preliminary exploration with the Doppler probe, immediately followed by the laser tip advancement along the vascular tonsil axis, took very few minutes. Treatment was well tolerated even in patients displaying a low pain threshold, and no dropout or uncompleted procedure was noted. The back and forth fibre optic movements across the lymphatic tissue and far enough from the vascular network created multiple empty channels (between 30 and 120) without completely collapsing the structure. Minor complications are summarized in Table 1. General discomforts, such as cough, pruritus, dysphagia and dryness, were also common among the patients (Table 1). The summary of postoperative pain in the 7 days following the first session, as measured by Scott–Huskisson VAS, was 21.5 ± 2.2 mm (mean ± SEM; range 5–40 mm) and easily counteracted by means of ice packages applied around the neck, nonsteroidal anti-inflammatory drugs and other drugs according to the individual patient’s need (Table 1). During the 12–36-month follow-up patients showed improved symptoms (n = 7) and complete recovery (n = 13). A relapse episode was observed in two patients. The procedure was safe since no serious adverse events, including haemorrhagic complications, occurred. The pain perceived was of low intensity, and after the procedure, the patient was allowed to drink and eat without any further complications.
The present study describes the use of a Doppler-guided fibre optic neodymium-YAG laser to remove up to 80 % of tonsillar tissue. We named this procedure “cribriform intracapsular tonsillectomy” or Swiss-cheese laser tonsillectomy. This procedure consists in a multi-drilled total or subtotal parenchyma removal, leaving the membrane and vascular stromal network in place. At the 12–36 month follow-up, among 20 patients, 7 patients showed an improvement in symptoms and 13 showed a full recovery. Two patients reported a relapse episode. Treatment was well tolerated with no untoward effects. Postoperative pain at day 7 following the first session was between 5 and 40 mm. Therefore, the present approach allows achieving relatively painless removal of tonsillar tissue safely and with promising results.
According to the literature, several tonsillectomy-related complications may occur. Selected tonsillar tissue destruction by a small-sized laser fibre optic is a safer option compared with the traditional cold knife approach or electrosurgery. In this article, we describe a procedure that encloses a Doppler-assisted neodymium-YAG surgical procedure to identify vascular topography, thus preventing any damage to the vascular network during the fibre optic insertion and, through the capsule, into the affected parenchyma.
We argue that cold knife tonsillectomy is cumbersome and time-consuming, and we suggest to preliminarily explore, step by step, by means of Doppler probe, the tonsillar parenchyma along the fibre optic direction. The procedure is followed by laser parenchyma ablation. In our experience, the creation of multiple channels into the lymphatic tissue was very effective to remove either hyperplastic or chronically infected tonsils, and offered a better quality of life in terms of pain control, immediate swallowing, eating and precocious recovery. As to the laser source, we had preliminary comparative experience with argon, CO2, fibre optic diode and neodymium-YAG laser. Argon and CO2 laser did not reach any substantial advancement in the surgical outcome and were quite cumbersome to be used across the tonsils resulting in relevant pain. The fibre optic innovation opens new perspectives in tonsillar surgery, rendering the procedure very easy and individually tailored to the tonsils’ anatomy and pathology. Our strategy, consisting in coupling Doppler and fibre optic in the same handle, was fundamental to achieve the goal of the procedure without risks. The neodymium-YAG source is the most effective in terms of simple use and energy quality as it is an optimal choice in the operating room. We routinely adopted the 320-μm fibre optic diameter, being the safest possible in terms of minimal damage to the surrounding tissue and the selectivity of minor vessel coagulation. In fact, no haemorrhage was observed in our cases, and haemostasis was excellent and safe due to the previous identification of the major tonsillar vessels and, more generally, to the vascular parenchymal network. This laser approach, compared with cold knife tonsillectomy, leaves some sterilized necrotic debris and cluster particles that might elicit a better immunological response against infectious agents. It can also explain the long-term successful outcome of the fibre optic procedure extended to the pharyngo-tonsillar area that is very often involved in the inflammatory process. In conclusion, fibre optic laser procedure can be the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost–benefit ratio, precise targeting of the beam across affected tissues and short- and long-term recovery.
Conflict of interest
The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. This study was performed according to the Helsinki Declaration. Local IRB approval was obtained.
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