Double-blind randomized control trial of coblation tonsillo-tomy versus coblation tonsillectomy on post-operative painin children

8 July 2005

Sir,

We write in reference to the paper entitled ‘Double-blind

randomized Control trial of coblation tonsillotomy versus

coblation tonsillectomy on post-operative pain in chil-

dren’ by Arya et al.1

There were a number of queries with the paper and we

are interested to hear the authors’ response.

1 A literature search for tonsillotomy in the English lan-

guage journals advocates its use in treating obstructive

sleep apnoea and tonsillar hypertrophy.2,3 The authors do

not provide any evidence that tonsillotomy is a suitable

treatment for recurrent tonsillitis.

2 The initial power calculation to determine the number

of patients necessary to achieve statistically significant

outcomes is based on a difference in pain equated to a

two point difference on a four point visual analogue

scale. The authors have then used an Area under curve

(AUC) analysis to determine if there is a difference in

pain between the two techniques. We agree that AUC is a

better technique for assessing pain, but this should have

formed the basis for the power calculation.

3 The use of a picture of faces for a visual analogue scale

(VAS) is well recognized, but why did the authors choose

a four point scale rather than the more commonly used

five- or 10 point scale?

4 No explanation is given in the paper regards why a

setting of eight was used to perform a tonsillotomy and a

setting of six was used to perform a tonsillectomy?

5 The authors state that when performing tonsillotomy

an ‘equivalent amount’ of tonsil tissue was removed as

with tonsillectomy on the contra-lateral side. It is stated

that patients with asymmetric appearance were excluded

but on occasion the asymmetry will only become appar-

ent at operation. The authors have not stated as to

whether tonsil tissue was therefore left behind in certain

cases. If tonsil tissue was left behind, were the parents

warned regarding the consequences of remnant tonsil

during consent, especially as the procedure was being

performed for recurrent tonsillitis?

6 Pain scores were only recorded for the first 24 h post-

operatively. The authors have recognized that pain can

persist for up to 2 weeks post-operatively. Despite this

why did they not attempt to use telephone or postal

questionnaires to collect pain scores during this 2-week

period. The patient would have completed the question-

naire four times during their inpatient stay. Therefore,

they should be able to provide an appropriate response to

a telephone or postal questionnaire without any of the

concerns the authors raise.

7 The authors state that a strict analgesia protocol was

used but only state that an opiate analgesic was given in-

traoperatively. Did all patients receive identical pre-,

intra- and post-operative analgesia [opiates, non-steroidal

anti-inflammatory drugs (NSAIDS), paracetamol]?

8 The age range of the patients was 3–14 years, we have

some doubt as to whether the children, especially the

younger ones, could differentiate between left and right

sided pain. The study the authors use in support4 was

performed in adult patients and not children. They pro-

vide no other evidence to support their view that children

can differentiate subtle differences between left and right

throat pain.

9 The primary haemorrhage rate in this small study is

5% (1/19 cases) and the authors still advocate coblation

as a suitable method for tonsillectomy.

We look forward to the authors’ responses.

Sincerely,

Ram Moorthy & Andrew ScottOtolaryngology-Head and Neck Surgery, Department of ENT,

Royal Shrewsbury Hospital, Shrewsbury, Shropshire, UK,

E-mail: rampers75@hotmail.com

References

1 Arya A.K., Donne A. & Nigam A. (2005) Double-blind rando-

mized control study of coblation tonsillotomy versus coblation

tonsillectomy on postoperative pain in children. Clin. Otolaryngol.

30, 226–229

2 Koltai P.J., Solares C.A., Koempel J.A., et al. (2003) Intracapsular

tonsillar reduction (partial tonsillectomy): reviving a historical

procedure for obstructive sleep disordered breathing in children.

Otolaryngol. Head Neck Surg. 129, 532–538

3 Densert O., Desai H., Eliasson A. et al. (2001) Tonsillotomy in

children with tonsillar hypertrophy. Acta Otolaryngol. 121, 854–

858

4 Arya A.K., Donne A. & Nigam A. (2003) Double-blind rando-

mized control study of coblation tonsillotomy versus coblation

tonsillectomy on postoperative pain. Clin. Otolaryngol. 28, 503–

506

CO

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ESPO

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Correspondence 571

� 2005 Blackwell Publishing Limited, Clinical Otolaryngology, 30, 566–576