design and preclinical safety assessment. Nat Sci Sleep. 2016;8:249-
10. Ugur KS, Ark N, Kurtaran H, et al. Anterior palatoplasty for selected
mild and moderate obstructive sleep apnea: preliminary results. Eur
Arch Otorhinolaryngol. 2014;271:1777-1783.
Accepted: 22 December 2017
Cold/cold vs. bipolar dissection tonsillectomy: A surgeon-
controlled study of 400 cases
Tonsillectomy represents 40% of the procedures performed in oto-
laryngology departments; equivalent to 45 000 tonsillectomies in the
UK each year.
The tonsillectomy procedure consists of 2 phases: tonsil excision
and haemostasis, which can be classified as “hot” or “cold.”
Hot Excision: Bipolar diathermy involves high-frequency electric
current being applied directly to the tonsil tissue from forceps.
Cold Excision: Steel dissection involves an incision being made in
the mucosa with scissors and mobilisation of tonsil using dissect-
Hot Haemostasis: Diathermy heat coagulates vessels within tissue.
Cold Haemostasis: Swabs control initial then ligatures control
A combination of techniques can be employed to create an
entirely hot, cold or combined approach. Bipolar diathermy is used
by many ENT surgeons in the UK at present.
Post-tonsillectomy haemorrhage (PTH) is a serious complication,
leading to a re-admittance rate of approximately 3-5%.
PTH is clas-
sified as primary, bleeding that occurs within 24 hours of the proce-
dure or secondary, within 2-14 days. The extent of PTH may
necessitate return to theatre (RTT) to control the bleeding.
Currently, there is no guidance from NICE recommending the
use of one technique over the other and the 2005 guidelines state:
“Surgeons should review the rates of haemorrhage complicating ton-
sillectomy in the techniques they use. Publication about the influ-
ence of different techniques on the incidence of haemorrhage after
tonsillectomy would be useful.”
This study aimed to compare hot and cold tonsillectomy tech-
niques to determine the relative rates of PTH and RTT, thus allowing
optimisation of future patient safety.
Based on evidence published by S
oderman in 2015, 2 consul-
tant ENT surgeons at Worcestershire Hospitals Acute Trust
(WHAT) ENT Department changed their tonsillectomy technique
from a hot/hot (bipolar diathermy) to a cold/cold approach
(cold-steel dissection + ligature without diathermy to control
This change allowed an opportunity to study
the effect of change in technique while controlling surgical
All patients who underwent tonsillectomy from January
2014 to October 2016 under the care of these 2 ENT consul-
tants were identified from theatre log books. Procedures per-
formed by the consultants and their teams (SpR and middle-
grade surgeons) were included in the analysis. Trainee and mid-
dle-grade surgeons were asked to attempt cold/cold dissection
after June 2015 wherever possible. The bipolar cases, com-
pleted prior to June 2015, were reviewed retrospectively and
the cold-steel cases, completed after June 2015 reviewed
Patients who underwent adenotonsillectomy were included in
the sample; however, those who underwent adenoidectomy alone or
tonsillectomy as part of a wider procedure such as neck dissection
Data were collected from the scanned document system eZ
Notes to record: patient age, grade of operating and supervising sur-
geon, technique of tonsil excision and haemostasis and re-admit-
tance and/or RTT for primary or secondary PTH. Operation notes
included details of the tonsillectomy techniques used during the
study period and this documentation was completed by the operat-
ing surgeon: it is assumed to be an accurate account of technique
used. The authors reviewed operation notes, discharge and Emer-
gency Department clerking sheets for 14-day post-tonsillectomy to
capture relevant data.
The data were transcribed into Microsoft Excel. Data on tonsillec-
tomy technique and postoperative outcome are presented as num-
ber of patients and percentage (n (%)) to allow comparison with
existing literature. Both intention-to-treat and per protocol analysis
are presented. This is necessary because several cold/cold proce-
dures were converted to cold/hot or hot/hot.
CORRESPONDENCE: OUR EXPERIENCE