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Randomised-controlled study comparing post-operativepain between coblation palatoplasty and laser palatoplasty
10 July 2006
Sir,
We read with interest the paper regarding the use of
coblation for palatoplasty and felt compelled to raise
several points of concern in interpreting this data.1 First,
by introducing tonsillectomy to one group in the study,
there is no direct comparison of surgical procedures as
one group is clearly receiving an additional procedure
and this should have been tackled as a separate study.
Possibly, these patients were also part of a coblation
tonsillectomy study? Secondly, patients with obstructive
sleep apnoea (OSA), medical co-morbidity and concomit-
ant surgery were excluded. Surely patients with OSA are
those most likely to benefit from the procedure and there-
fore should have been included rather than excluded?
Patients attending for snoring surgery are also reasonably
likely to have some degree of medical co-morbidity and
inclusion of these subjects would have enabled the study to
be more reflective of routine clinical practice.
Thirdly, it appears that subjects were withdrawn if
further analgesia was required over the standard regimen
of co-codamol and ibuprofen or if they received antibiotics
for an oropharyngeal infection. Again this would seem to
bias the results when one of the outcome measures is
pain scoring. Finally, analysis of the results found that
pain scores were only better in the second week post-op
based on median rather than mean scores and that
analgesia usage differences were not statistically significant
between the two groups. Along with this snoring loudness
levels were no different between the two groups statisti-
cally, although LAUP group were better. The authors
conceded that the LAUP long-term snoring loudness
results were better and this is likely to be due to the scar-
ring associated with the use of the laser. Given all the
above limitations of this study, the conclusion seems to
be clear that using coblation, which minimises scarring
and gives a somewhat questionable reduction in post-
operative pain, should probably be discouraged in favour
of a technique such as laser or diathermy likely to pro-
duce some scarring that will help achieve a significant
reduction in snoring which is the reason the patients
darkened the clinic door in the first place.
Philpott, C.M., & Tassone, P.Departments of Otorhinolaryngology, West Suffolk Hospital and
Norfolk and Norwich University Hospital, Norwich, UK
E-mail: [email protected]
Reference
1 Belloso A., Morar P., Tahery J. et al. (2006) Randomised-con-
trolled study comparing post-operative pain between coblation
palatoplasty and laser palatoplasty. Clin. Otolaryngol. 31, 138–143
Response to Philpott and Tassone
19 July 2006
Sir,
We read with laconic interest the comments about our
paper comparing post-operative pain between Coblation
and Laser Palatoplasty. We were fully aware that we were
comparing slightly different surgical techniques and the
possible impact on the results of the paper. The reason
why we have included tonsillectomy in the coblation
group is because that was our routine coblation palato-
plasty technique; and in an attempt to reflect our clinical
practice, we designed a study comparing our standard
Laser technique for palatoplasty (without tonsillectomy)
with our standard Coblation palatoplasty technique (with
tonsillectomy). We have already explained in the paper
that because the post-operative pain is significantly less
in the group with more extensive surgery (coblation +
tonsillectomy group), that the results were even more
clinically significant. A different viewpoint can hypothe-
sise that the coblation group would be even less painful if
it did not include tonsillectomy, and the pain differences
would be even greater; but this is only a supposition.
A second-point questioned is our inclusion/exclusion
criteria. It is normal practice in our unit to treat patients
with obstructive sleep apnoea (OSA) medically with con-
tinuous positive airway pressure and during our study
period no OSA patients were listed for palate surgery.
The medical co-morbidity was low and few patients were
excluded on those grounds. Those exclusions were
applied before randomisation and therefore did not affect
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Correspondence 463
� 2006 The Authors
Journal compilation � 2006 Blackwell Publishing Limited, Clinical Otolaryngology, 31, 456–469
the distribution of patients in the study groups. We deci-
ded to withdraw from the study any patient with any
extra medications, which could interfere with post-
operative pain control. That was the case in three
patients in the coblation group and two patients in the
Laser group. We agree that can represent a bias; but we
considered a major bias the inclusion of patients with
extra medication.
We have to disagree about the remarks about statistic
analysis. Pain scores were lower in the coblation group
during the study period and statistically significant during
the second week. Data were of non-normal distribution
and therefore was analysed with a non-parametrical test.
Non-parametrical tests use the median and quartiles
instead of median and standard deviation. The use of
mean values to explain our results can be misleading
because they will be easily influenced by extreme values,
always present in small groups. We would recommend
consulting a colleague with knowledge of statistics and
re-reading the paper.
Finally, we find interesting your suppositions about
reduction of snoring between techniques. As we explain
abundantly clearly in the paper, our power and follow-up
period were insufficient to draw any conclusions at all
regarding long-term snoring control and we find it
remarkable that you have been able to build a theory
from our results. Nevertheless, these are interesting sup-
positions that may be merit a study to investigate them.
Belloso, A., Morar, P., & Timms, M.S.Department of Otorhinolaryngology,
Queens Park Hospital, Blackburn, UK,
E-mail: [email protected]
Semont’s manoeuvre in BPPV: a forgotten technique
30 May 2006
Sir,
We remind a method, not commonly used in a general
UK ENT clinic, which has very good results for patients
with benign positional paroxysmal vertigo (BPPV) after
Epley has failed. BPPV is a common cause of dizziness.
The diagnosis is suggested by a history of brief episodes
of vertigo provoked by rolling over in bed, lying down,
sitting up from a supine position, bending over, or look-
ing up. Dix and Hallpike1 provided both the provocative
manoeuvre necessary for the accurate diagnosis of the
condition, as well as all the classic features of the accom-
panying nystagmus: latency, direction, duration, reversal
and fatigability. Convincing evidence in support of
canalolithiasis as an explanation for BPPV validates treat-
ment with any procedure that can clear the canaliths
from the posterior semicircular canal.2
Epley3 described the canalith repositioning manoeuvre,
a very effective method with a cure rate of >80%.4 In case
of failure, the manoeuvre is usually repeated once or
twice, but if the symptoms remain, a shorter reposition-
ing procedure, the liberating or Semont’s manoeuvre can
be used.5 Treatment is completed in four steps:
1 The head is turned 45� away from the affected side
(this is the main difference from the Epleys, which always
starts from the symptomatic side).
2 The patient is then brought briskly to the side-lying posi-
tion, with the occiput resting on the couch and the affected
ear downward. This position is maintained for at least
1 min, some will keep the patients there up to 3 min.
3 Then, the patient is briskly turned through the original
sitting position to the opposite side-lying position with
the head still turned towards the unaffected side, the fore-
head against the surface.
4 After 1–3 min, the patient is returned to the original
sitting position. Throughout the manoeuvre the head
remains turned towards the same shoulder, away from
the affected side. Following the procedure, advice must be
given to the patient to sleep with a 45� incline, avoid
turning the head or sleeping on the ‘bad’ side for a week.
The manoeuvre requires a brisk movement of the patient
and is relatively contraindicated in patients with limited
neck or spine mobility. In cases of failure of both Epley’s
and Semont’s manoeuvre and assuming the diagnosis is
right, neck exercises (Brandt–Daroff) can be used safely at
home.Karkos, P.D.,* Leong, S.C.,� Papouliakos, S.M.,�
Korres, S.G.,� & Thong, J.F.,�
Department of Otolaryngology,
*Royal Liverpool University Hospital, Liverpool, UK,
Liverpool, �St George’s Hospital and Medical School,
London, UK, and�Hippokration Hospital, University Hospital Athens, Athens,
Greece,
E-mail: [email protected]
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464 Correspondence
� 2006 The Authors
Journal compilation � 2006 Blackwell Publishing Limited, Clinical Otolaryngology, 31, 456–469
