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Entgr Tonsillectomy

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Entgr Tonsillectomy

  1. 1. Tonsillectomy: A Review of Methods and Adjunctive Therapy in 2005 <ul><li>David Kluge, MD </li></ul><ul><li>Division of Otolaryngology-Head and Neck Surgery </li></ul><ul><li>November 3, 2005 </li></ul>
  2. 2. Objectives <ul><li>Examine the various methods of tonsillectomy. </li></ul><ul><li>Assess the role and mechanism of action of post-operative antibiotics in tonsillectomy. </li></ul><ul><li>Examine the role of peri-operative steroids in tonsillectomy as currently accepted in the literature. </li></ul>
  3. 3. Doctor, I want the newest, best and most pain-free tonsillectomy for my child or I will go somewhere else…
  4. 4. What is “new”? <ul><li>The newer methods of tonsillectomy include: </li></ul><ul><ul><li>Coblation </li></ul></ul><ul><ul><li>Harmonic scapel </li></ul></ul><ul><ul><li>Ligasure (Thermal Welding) </li></ul></ul><ul><ul><li>Laser </li></ul></ul><ul><ul><li>Intra-capsular methods </li></ul></ul>
  5. 5. “ Old Methods” <ul><li>Electrocautery </li></ul><ul><li>Cold Knife </li></ul>
  6. 6. What is the “best” <ul><li>One of the main objectives for this lecture </li></ul><ul><li>Must integrate all the information and studies to make the right decision for the patient </li></ul><ul><li>May vary based on patient population </li></ul>
  7. 7. “ Pain-free” tonsillectomy <ul><li>Certain methods are associated with less post-operative pain </li></ul><ul><li>But are these methods also associated with increased bleeding or other risks? </li></ul>
  8. 8. Overview <ul><li>Review of methods </li></ul><ul><li>Review of adjunctive therapies </li></ul><ul><li>Conclusion </li></ul>
  9. 9. Disclaimer <ul><li>The information presented is a brief overview of the vast information available on methods and adjunctive therapies for tonsillectomy </li></ul><ul><li>My conclusions are based on the overall consensus of the most recent studies available </li></ul><ul><li>New information is being published weekly in this area </li></ul><ul><li>Please review the bibliography for more information </li></ul>
  10. 10. Cold Knife <ul><li>Involves a combination of sharp and blunt dissection +/- snare to complete the inferior amputation </li></ul><ul><li>Guillotine method-now out of favor-but studies show very low post tonsillar hemmhorage rates as well as low post operative pain levels </li></ul>
  11. 11. Cold Knife-Advantages <ul><li>Overwhelming evidence to indicate less post-operative pain </li></ul><ul><li>Conflicting evidence for post tonsillectomy hemorrhage (PTH) but probably less common than electrocautery </li></ul><ul><li>Least expensive method </li></ul>
  12. 12. Cold Knife-Disadvantages <ul><li>Overwhelming evidence to indicate more intra-operative blood loss </li></ul><ul><li>Variable data on PTH, if it does occur it will occur earlier than cautery and is not usually as severe </li></ul><ul><li>Will cause bacteremia, unlike other methods </li></ul><ul><li>Usually takes longer than cautery especially if bleeding occurs </li></ul>
  13. 13. Cold Knife-Conclusions <ul><li>Still the “Gold Standard” </li></ul><ul><li>Trade high intraoperative blood loss for less post-operative pain </li></ul><ul><li>Inexpensive </li></ul><ul><li>A great method for most children and adults. Low pain, hospital costs and PTH rates </li></ul>
  14. 14. Electrocautery: Monopolar and Bipolar <ul><li>Monopolar cautery is currently the most common method of tonsillectomy in the United States </li></ul><ul><li>Bipolar cautery has received more attention in the last few years and is commonly used internationally </li></ul><ul><li>Suction cautery has also been described but is not extensively used </li></ul>
  15. 15. Electrocautery: Monopolar and Bipolar <ul><li>Electrocautery is based on tissue dessication to achieve dissection and hemostasis </li></ul><ul><li>There is very high local energy transfer that heats tissue to high temperatures </li></ul>
  16. 16. Electrocautery Principles <ul><li>The post-operative pain associated with cautery is attributed to the spread of thermal injury </li></ul><ul><li>The “newer” methods of tonsillectomy attempt to minimize this ‘colateral damage’ </li></ul><ul><li>Using cut or blend instead of coag may decrease post-operative pain (good study needed here) </li></ul>
  17. 17. Electrocautery: Monopolar and Bipolar-Advantages <ul><li>Minimal intraoperative bleeding </li></ul><ul><li>Probably the quickest method </li></ul><ul><li>Small handpiece </li></ul><ul><li>Inexpensive </li></ul><ul><li>“ Tried and True” method </li></ul>
  18. 18. Electrocautery: Monopolar and Bipolar-Disadvantages <ul><li>Highest post-operative pain </li></ul><ul><li>May have a higher PTH rate than cold knife </li></ul><ul><li>SMOKE! </li></ul><ul><li>Possibility for endotracheal tube fire </li></ul>
  19. 19. Electrocautery: Monopolar and Bipolar-A Word about Bipolar <ul><li>Seems to offer lower post-operative pain levels with the same PTH rate as monopolar cautery </li></ul><ul><li>Minimal increase in operative time over monopolar </li></ul>
  20. 20. Electrocautery: Monopolar and Bipolar-A Word about Smoke <ul><li>Not usually an issue in tonsillectomy as it is suctioned by the surgical assistant </li></ul><ul><li>However it should be treated like laser smoke and aggressively removed from all surgical fields especially those known to contain virus or cancer cells </li></ul>
  21. 21. No Smoking <ul><li>NIOSH (the National Institute of Occupational Safety and Health) and the CDC (Center for Disease Control) have studied electrosurgical smoke at length. They state: </li></ul><ul><ul><li>“ Research studies have confirmed that this smoke plume can contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses.” </li></ul></ul>
  22. 22. Electrocautery: Monopolar and Bipolar-Conclusions <ul><li>Low intraoperative blood loss </li></ul><ul><li>Possibly higher PTH rates than cold knife </li></ul><ul><li>Highest pain </li></ul><ul><li>A good method for immediate hemostasis and speed but at the cost of higher pain </li></ul>
  23. 23. Coblation <ul><li>Uses radiofrequency (RF) energy to ionize NaCl in a saline medium, then the energy of these ions (plasma) is used to break molecular tissue bonds </li></ul><ul><li>May also be used for direct hemostasis </li></ul><ul><li>RF energy is supposed to stay in the irrigation to minimize collateral heating </li></ul><ul><li>Temperatue is not supposed to exceed 70 C (cautery is routinely 200-400 C) </li></ul>
  24. 24. Coblation Tonsillectomy Demonstration
  25. 26. Coblation-Advantages <ul><li>Most studies indicate less pain than electrocautery, some cite equivalent pain to cold knife </li></ul><ul><li>Intraoperative blood loss comparable to electrocautery </li></ul><ul><li>No electrical connection to patient </li></ul>
  26. 27. Coblation Physician Contacts Stoker et al, Otolaryngol Head Neck Surg 204; 130: 666-75
  27. 28. Coblation-Post Op Pain Stoker et al, Otolaryngol Head Neck Surg 204; 130: 666-75
  28. 29. Coblation-Disadvantages <ul><li>Very high cost compared to electrocautery or cold knife ($150-200/piece) </li></ul><ul><li>Current studies are highly variable, but rates of PTH seem to be equivalent to electrocautery or may even be higher </li></ul><ul><li>Operative times up to twice as long than electrocautery </li></ul><ul><li>Aggressive marketing campaign targeted to lay public </li></ul>
  29. 30. Coblation-Conclusions <ul><li>Still a new and relatively untested method </li></ul><ul><li>High level of conflicting data especially on rate of PTH </li></ul><ul><li>Very expensive </li></ul><ul><li>An expensive alternative to cold knife for pain with higher PTH rates </li></ul>
  30. 31. Harmonic Scalpel <ul><li>Blade vibrates at 55,500 hertz </li></ul><ul><li>This vibration is in the RF range and causes proteins to denature and form a coagulum which seals small vessels and divides tissue </li></ul><ul><li>Larger vessels can be sealed by continuous contact and secondary heating </li></ul>
  31. 32. Harmonic Scalpel <ul><li>Recurrent theme in post operative pain is spread of thermal injury </li></ul><ul><li>Coblation, harmonic scalpel and thermal welding were designed to minimize this spread </li></ul>
  32. 33. Harmonic Scalpel-Advantages <ul><li>Lower post-operative pain than electrocautery </li></ul><ul><li>Intraoperative blood loss comparable to electrocautery </li></ul><ul><li>Possibly lower PTH rates than electrocautery </li></ul><ul><li>No electrical connection to patient </li></ul>
  33. 34. Harmonic Scalpel-Disadvantages <ul><li>Expensive </li></ul><ul><li>Longer operative time than electrocautery or cold knife </li></ul>
  34. 35. Harmonic Scalpel-Conclusions <ul><li>Higher cost with longer operating times </li></ul><ul><li>PTH rates about the same as electrocautery </li></ul><ul><li>Less post operative pain </li></ul><ul><li>Probably a better choice than coblation among the ‘new’ methods based on a lower PTH rate </li></ul>
  35. 36. Thermal Welding <ul><li>Variation of bipolar cautery and bipolar scissors </li></ul><ul><li>Feedback system to automatically control ‘seal cycle’ </li></ul><ul><li>Minimizes thermal spread </li></ul><ul><li>Rated for up to 7 mm vessels at 3x normal SBP </li></ul><ul><li>‘ Melts’ collagen and elastin to form a coagulum similar to plasma and harmonic scalpel </li></ul><ul><li>Does not rely of proximal thrombus like standard electrocautery </li></ul><ul><li>Also used for neck surgery and thyroid surgery </li></ul><ul><li>May eventually replace standard bipolar </li></ul>
  36. 37. Thermal Welding-Advantages <ul><li>Would seem to have less post operative pain than monopolar electrocautery </li></ul><ul><li>Cost is less than Coblation and Harmonic scalpel </li></ul>
  37. 38. Thermal Welding-Disadvantages <ul><li>Very new </li></ul><ul><li>PTH rates unknown </li></ul><ul><li>Still more costly that monopolar and cold knife </li></ul><ul><li>Only studies available are subsidized by ValleyLab </li></ul>
  38. 39. Thermal Welding-Conclusions <ul><li>Too new-many unknowns </li></ul><ul><li>Cost will probably be mid range among the ‘new’ methods </li></ul><ul><li>Lower pain, unknown PTH rates </li></ul><ul><li>A risky choice at this time, however technology seems solid </li></ul>
  39. 40. Intracapsular Excision (Tonsillotomy) <ul><li>Advantages </li></ul><ul><ul><li>Less post operative pain </li></ul></ul><ul><ul><li>Probably lower PTH rate </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Opportunity for tonsillar regrowth </li></ul></ul><ul><ul><li>Still serves as a nidus for infection </li></ul></ul><ul><ul><li>May require formal tonsillectomy in future </li></ul></ul>
  40. 41. Intracapsular Methods <ul><li>Powered microdebrider </li></ul><ul><li>Coblation </li></ul><ul><li>Bipolar Scissors </li></ul><ul><li>Laser </li></ul>
  41. 42. Microdebrider <ul><li>Same instrument as used in adenoidectomies </li></ul><ul><li>Requires cauterization for hemostasis </li></ul>
  42. 43. Coblation Intracapsular Tonsillotomy Demonstration
  43. 45. Bipolar Scissors <ul><li>Newer method utilizing older technology </li></ul><ul><li>By far, the quickest method of intracapsular tonsillotomy </li></ul><ul><li>Also used for tonsillectomy: </li></ul><ul><ul><li>Post operative pain for total tonsillectomy is actually similar to cold knife in at least two studies </li></ul></ul><ul><ul><li>PTH rates similar to monopolar cautery </li></ul></ul>
  44. 46. Laser <ul><li>Used for debridement of hypertrophied tonsils </li></ul><ul><li>Several laser types used </li></ul><ul><li>Typically leaves 10-25% of tonsil tissue behind </li></ul><ul><li>Associated with lower post-operative pain than electrocautery </li></ul>
  45. 47. Best Among Intracapsular Techniques <ul><li>Pain level amongst all techniques are likely to be similar as none penetrate the capsule </li></ul><ul><li>Bipolar scissors seem to offer great immediate hemostasis and quick operative times </li></ul><ul><li>Coblation is slower and more expensive </li></ul><ul><li>Microdebrider requires cautery for hemostasis </li></ul><ul><li>Laser is probably a good technique, however dissection may be more difficult to control </li></ul>
  46. 48. Best Among Intracapsular Techniques <ul><li>Overall, the bipolar scissors are probably the best method when taking operative time and cost into account; assuming the rate of PTH and post operative pain levels are the same. </li></ul>
  47. 49. Doctor, I want the newest, best and most pain-free tonsillectomy for my child or I will go somewhere else…
  48. 50. Which is ‘Best’ choice now? <ul><li>It Depends </li></ul><ul><ul><li>What is important? </li></ul></ul><ul><ul><ul><li>PTH rates </li></ul></ul></ul><ul><ul><ul><li>Post operative pain </li></ul></ul></ul><ul><ul><ul><li>Intraoperative bleeding </li></ul></ul></ul><ul><ul><ul><li>Operative time </li></ul></ul></ul><ul><ul><ul><li>Cost </li></ul></ul></ul><ul><ul><ul><li>Possible tonsillar regrowth </li></ul></ul></ul><ul><ul><ul><li>Chance for bacteremia </li></ul></ul></ul>
  49. 51. Adjunctive Therapy <ul><li>Basic catagories </li></ul><ul><ul><li>Perioperative steroids </li></ul></ul><ul><ul><li>Operative hemostasis (bismuth/afrin) </li></ul></ul><ul><ul><li>Post operative antibiotics </li></ul></ul><ul><ul><li>Local Anesthetic </li></ul></ul><ul><ul><li>Post operative pain control </li></ul></ul>
  50. 52. Perioperative Steroids <ul><li>Numerous studies over decades have repeatedly shown no adverse effects with one dose of perioperative steroids. </li></ul><ul><li>Multiple studies have also shown reduction in post operative pain levels and 24 hr emesis rates </li></ul><ul><li>Study dosages range from 0.1-1.0 mg/kg up to a total dose of 50 mg </li></ul>
  51. 53. Emesis Reduction Steward et al, Laryngoscope 111: October 2001
  52. 54. Return of Diet Steward et al, Laryngoscope 111: October 2001
  53. 55. Cochrane Database of Systematic Reviews. 4, 2005 <ul><li>The evidence suggests that a single intravenous dose of dexamethasone is an effective, relatively safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy. No adverse events attributable to dexamethasone were reported in these trials. Additionally, in our 10-year experience of routine use of a single intravenous dose of dexamethasone during pediatric tonsillectomy, there have been no attributable, adverse events. Lastly, we found no reports in the literature of complications from use of a single intravenous dose of corticosteroid during pediatric tonsillectomy. </li></ul>
  54. 56. Bismuth/Afrin <ul><li>Bismuth is an activator of factor XII (Hageman Factor) in vitro </li></ul><ul><li>Studies are mixed and most do not separate the Afrin effect from the bismuth </li></ul><ul><li>Hemostatic effect (if any) maybe due entirely to the Afrin and not bismuth </li></ul><ul><li>Bismuth aspiration has been associated with post operative morbidity including death </li></ul>
  55. 57. Bismuth/Afrin <ul><li>Overall, there is no consensus in the literature as to the effectiveness </li></ul><ul><li>The combination may be harmful if aspirated </li></ul><ul><li>Prudent, not routine, usage is probably justifiable </li></ul><ul><li>Afrin soaked sponges may work just as well (a straightforward study idea) </li></ul>
  56. 58. Post Operative Antibiotics <ul><li>Now generally accepted in the literature as routine </li></ul><ul><li>Some disagreement on type and duration </li></ul><ul><li>Most studies recommend a 5-7 day course of narrow spectum (amoxicillin) antibiotics </li></ul><ul><li>Thought to decrease post operative pain and post operative healing time by decreasing the bacterial oral flora </li></ul>
  57. 59. Local Anesthetics <ul><li>Three major catagories </li></ul><ul><ul><li>Pre-surgical injection </li></ul></ul><ul><ul><li>Post-surgical injection </li></ul></ul><ul><ul><li>Topical administration post operatively </li></ul></ul>
  58. 60. Cochrane Database of Systematic Reviews. 4, 2005 <ul><li>There is no evidence that the use of perioperative local anaesthetic in patients undergoing tonsillectomy improves post-operative pain control. The trials identified were of small size and several involved the perioperative co-administration of intravenous opiates which may have masked any beneficial effect of the local anaesthetic. Further randomised controlled trials are necessary. </li></ul>
  59. 61. Post Operative Pain Control <ul><li>Tylenol </li></ul><ul><li>Narcotics (and tylenol/narcotic combonations) </li></ul><ul><li>NSAIDS </li></ul>
  60. 62. Narcotics and NSAIDS <ul><li>Children are routinely given Tylenol #3 </li></ul><ul><ul><li>The literature is mixed but it is a generally accepted practice </li></ul></ul><ul><ul><ul><li>Codeine can cause constipation, vomiting, and sedation </li></ul></ul></ul><ul><li>NSAIDS are controversial </li></ul><ul><ul><li>Ibuprofen, ketorolac and ketoprofen are the most commonly used </li></ul></ul><ul><ul><li>Some studies used the NSAIDS in the immediate perioperative period </li></ul></ul>
  61. 63. Cochrane Database of Systematic Reviews. 3, 2004 <ul><li>Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to relieve pain immediately after an operation. Because these drugs can interfere with blood clotting there has been concern that these drugs will increase bleeding in children having their tonsils out. This could be a problem because children have relatively small breathing airways and lower blood volume compared to adults. The present review found that, with present evidence, NSAIDs did not significantly increase the need to treat bleeding. There was less nausea and vomiting when NSAIDs were used as part of the analgesic regime, compared to when NSAIDs were not used. </li></ul>
  62. 64. Conclusions-Adjunctive Therapy <ul><li>Steroids </li></ul><ul><ul><li>Fully supported for 1 mg/kg up to 25-50 mg </li></ul></ul><ul><li>Bismuth/Afrin </li></ul><ul><ul><li>Good evidence for Afrin but very weak evidence for bismuth-recommend Afrin only packs </li></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>Fully supported. Type and duration controversial-recommend 5-7 days of limited spectrum abx </li></ul></ul>
  63. 65. Conclusions-Adjunctive Therapy <ul><li>Local Anesthetics </li></ul><ul><ul><li>Mixed data-Physician’s choice </li></ul></ul><ul><li>Post Operative Pain Control </li></ul><ul><ul><li>Plain Tylenol may be sufficient in young pts. NSAIDS are shown to be safe and effective and reduce narcotic complications without increasing bleeding. </li></ul></ul>
  64. 66. Overall Conclusions <ul><li>METHOD: Varies on what the physician considers important. However, for rates of post operative pain and PTH cold knife is clearly superior </li></ul>
  65. 67. Overview Lowest? Lowest? Lower Lower Lower Highest EBL Mid High Lower Lower Thermal Welding (Ligasure) High High Low Low Lowest Cost Mid-long Lower Lower Harmonic Scalpel Mid-long Unknown-HIGH? Lower Coblation Mid Mid-high Mid Bipolar Lowest Mid-high Highest Monopolar Mid-long Lowest Lowest Cold Knife OR Time PTH Pain
  66. 68. Selected Bibliography <ul><li>Bent, J.,April, M., Ward, R., Sorin, A., Reilly, B., Weiss, G. Ambulatory Powered Intracapsular Tonsillectomy and Adenoidectomy in Children Younger Than 3 Years. Arch Otolaryngol Head Neck Surg. 2004; 130: 1197-1200. </li></ul><ul><li>Cardwell M., Siviter G., Smith A. Non-Steroidal Anti-Inflammatory Drugs and Perioperative Bleeding in Paediatric Tonsillectomy. (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. </li></ul><ul><li>Carr, M., Williams, J., Carmichael, L., Nasser, J. Effect of Steroids on Posttonsillectomy Pain in Adults. Arch Otolaryngol Head Neck Surg.1999; 125: 1361-1364. </li></ul><ul><li>Chan, K., Friedman, N., Allen, G., Yaremchuk, K., Wirtschafter, A., Bikhazi, N., Bernstein, J., Kelley, P., Lee, K. Randomized, Controlled, Multisite Study of Intracapsular Tonsillectomy Using Low-Temperature Plasma Excision. Arch Otolaryngol Head Neck Surg. 2004; 130: 1303-1307. </li></ul>
  67. 69. Selected Bibliography <ul><li>Conley, S., Ellison, M. Avoidance of Primary Post-tonsillectomy Hemorrhage in a Teaching Program. Arch Otolaryngol Head Neck Surg. 1999; 125: 330-333. </li></ul><ul><li>Hall D., Littlefield, P., Birkmire-Peters, D. and Holtel, M. Radiofrequency ablation versus electrocautery in Tonsillectomy. Otolaryngol Head Neck Surg. 2004;130:300-5. </li></ul><ul><li>Isaacson, G. Inside-Out Complete Tonsillectomy: Extended Intracapsular Tonsillectomy for Severe Sore Throat. Ann Otol Rhinol Laryngol 2005; 114: 757-761. </li></ul><ul><li>Johnson, L., Elluru, R., Myer C. Complications of Adenotonsillectomy. Laryngoscope 2002; 112: 35–36. </li></ul><ul><li>Koltai, P., Solares, A., Mascha, E., Xu, M. Intracapsular Partial Tonsillectomy for Tonsillar Hypertrophy in Children. Laryngoscope 2002; 112: 17–19. </li></ul>
  68. 70. Selected Bibliography <ul><li>Lee, K., Bent J., Dolitsky, J., Hinchcliffe, A., Mansfield, E., White, A., Younis, R. Surgical advances in tonsillectomy: Report of a roundtable discussion. ENT Journal 2004; Suppl 3: 4-13. </li></ul><ul><li>Maddern, B. Electrosurgery for Tonsillectomy. Laryngoscope 2002; 112: 11–13. </li></ul><ul><li>Plant R., Radiofrequency Treatment of Tonsillar Hypertrophy. Laryngoscope, 2002; 112: 20–22. </li></ul><ul><li>Potts, K., Augenstein, A., Goldman, J. A Parallel Group Analysis of Tonsillectomy Using the Harmonic Scalpel vs Electrocautery. Arch Otolaryngol Head Neck Surg. 2005; 131: 49-51. </li></ul><ul><li>Salonen, A., Kokki, H., Nuutinen, J., Recovery After Tonsillectomy in Adults: A Three-Week Follow-up Study. Laryngoscope 2002; 112: 94–98. </li></ul>
  69. 71. Selected Bibliography <ul><li>Steward D., Welge J., Myer C. Do Steroids Reduce Morbidity of Tonsillectomy? Meta-Analysis of Randomized Trials. Laryngoscope 2001; 111: 1712–1718. </li></ul><ul><li>Stoker, K.,Don, D., Kang, R., Haupert, M., Magit, A. and Madgy, D. Pediatric Total Tonsillectomy Using Coblation Compared to Conventional Electrosurgery: A Prospective, Controlled Single-Blind Study. Otolaryngol Head Neck Surg. 2004; 130: 666-75. </li></ul><ul><li>Sorensen, W. T.,Henrichsen J., and Bonding P. Does Bismuth Subgallate Havw Haemostatic Effects in Tonsillectomy? Clin. Otolaryngol. 1999; 24: 72-74. </li></ul>
  70. 72. Selected Bibliography <ul><li>Sorin, A., Bent, J., April, M., Ward, R. Complications of Microdebrider-Assisted Powered Intracapsular Tonsillectomy and Adenoidectomy. Laryngoscope 2004; 114: 297–300. </li></ul><ul><li>Thomsen J., Gower V. Adjuvant Therapies in Children Undergoing Adenotonsillectomy. Laryngoscope 2002; 112: 32–34. </li></ul><ul><li>Wiatrak, B., Willging, P. Harmonic Scalpel for Tonsillectomy. Laryngoscope 2002; 112: 14–16. </li></ul><ul><li>Windfuhr, J., Deck J., Remmert, S. Hemorrhage Following Coblation Tonsillectomy. Ann Otol Rhinol Laryngol 2005; 114: 749-56. </li></ul>
  71. 73. Questions