NEW YORK (Reuters Health) – For selected adults, laser tonsillotomy under local anesthesia may be a feasible alternative to conventional tonsillectomy, achieving faster functional recovery times but leaving lingering symptoms, researchers say.
“Compared to classic dissection tonsillectomy, recovery after laser treatment is a lot faster with significantly fewer (patients experiencing) postoperative bleeding,” said Dr. Justin Wong Chung of Hagaziekenhuis, The Hague in The Netherlands.
“The laser treatment can be performed under local anesthesia in an outpatient setting, obviating the need for a full operating room and surgery team, including an anesthesiologist,” he noted. “This also leads to a reduction in costs and pressure on hospital resources.”
“More patients had persistent symptoms after tonsillotomy, and some had to have a second laser treatment as a result,” he acknowledged “The partial removal of the tonsil during the laser treatment leaves the possibility of residual lymphatic tissue that can cause persistent symptoms. Secondary treatment of the residual tissue often resolves the remaining complaints.”
As reported in JAMA Network Open, Dr. Wong Chung and colleagues randomized 199 patients (mean age, 29; 70%, women) in The Netherlands to either tonsillectomy (98) or tonsillotomy (101) from 2018-2019. After dropouts for various reasons, 97 received tonsillotomy whereas only 66 received tonsillectomy.
For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia; tonsillectomy consisted of total tonsil removal performed under general anesthesia.
The primary outcome was time to functional recovery measured within two weeks after surgery.
Recovery time after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for tonsillectomy vs. tonsillotomy, 0.3).
Two weeks after surgery, 77% patients in the tonsillotomy group were fully recovered compared with 57% in the tonsillectomy group. Time until return to work was also shorter after tonsillotomy (median, 4.5 days vs. 12.0 days; HR, 0.3.).
Postoperative hemorrhage occurred in two patients (2%) in the tonsillotomy group and eight (12%) in the tonsillectomy group.
At six months after surgery, fewer patients in the tonsillectomy group (35%) than in the tonsillotomy group (57%) experienced persistent symptoms, such as sore throat, snoring or dysphagia. Most with persistent symptoms in both the tonsillotomy (59%) and tonsillectomy (64%) groups reported that symptoms were mild.
Dr. Wong Chung said, “The laser treatment is not suitable in patients with a history of peritonsillar access because of its potentially lethal complications. The possibility of residual tonsil tissue that might lead to a recurrent infection is not acceptable in these patients.”
“We found that most adults can undergo laser treatment under local anesthesia very well,” he added. “In some patients, the gag reflex can seem problematic for treatment without narcosis, however, we found that the gag reflex can be easily decreased within two weeks with some practice at home.”
Dr. Erich Voigt, a clinical associate professor of Otolaryngology-Head and Neck Surgery at NYU Langone Health in New York City, commented in an email to Reuters Health, “I am not surprised that laser tonsillotomy results in an easier and faster recovery when compared with a conventional complete tonsillectomy.”
“However,” he noted, “laser tonsillotomy is not a replacement for conventional tonsillectomy, and laser tonsillotomy may not be appropriate for patients with severe tonsil infections; 57% of tonsillotomy patients had persisting symptoms at six months follow up compared to only 35% of tonsillectomy patients, suggesting that laser tonsillotomy is not as effective in treating tonsil disease.”
“It is also important to note that eight tonsillotomy patients required a conventional tonsillectomy after the initial procedure,” he added.
Dr. Omid Mehdizadeh, an otolaryngologist at Providence Saint John’s Health Center in Santa Monica, California, pointed out certain methodological limitations. Patients were not blinded, he said by email, which can introduce bias into the study. Many patients were lost to follow-up and the follow-up time was relatively short.
“Although in-office tonsillotomy patients experience less pain and an earlier return to work,” he added, “the procedure has not been demonstrated to be superior or effective in treatment of chronic and recurrent tonsillitis.”
SOURCE: https://bit.ly/3HvT1HW JAMA Network Open, online February 21, 2022.