Endoscopic‐assisted radiofrequency lingual tonsillectomy

Abstract

Lingual tonsil hypertrophy can have a significant negative impact on quality of life, with symptoms of upper airway obstruction, dysphagia, and sleep apnea.1 Medical management is typically unrewarding. Traditional techniques of lingual tonsillectomy (including monopolar cautery or laser) are associated with high morbidity, including significant pain, bleeding, and potential temporary worsening of airway obstruction due to postoperative edema.2-4 Surgical visualization of the hypertrophic lymphatic tissue is generally performed via suspension laryngoscopy, but most authors agree that the views are suboptimal, and working down the long shaft of the laryngoscope can hamper instrument mobility.5 As such, lingual tonsillectomy continues to be a procedure hampered with difficulties. Herein we describe our approach to lingual tonsillectomy, that being endoscopic-assisted with the use of controlled radiofrequency ablation (also known as Coblation). We will also review the currently available techniques for lingual tonsillectomy in comparison to our technique. Patients scheduled for lingual tonsillectomy must meet certain symptomatic inclusion criteria (such as sleep apnea or dysphagia) as well as undergo flexible nasopharyngoscopy to ensure that hypertrophic lingual tonsils are the sole source of their health concerns before proceeding to surgery. Once the diagnosis is established and consent obtained, patients are brought to the operating room for treatment. A preoperative anesthetic consultation is obtained in each case to formulate a plan for management of the shared airway. Preoperative medications (metronidzole [500 mg intravenously] and dexamethasone [4–8 mg, weight adjusted]) are administered. Patients are nasally intubated, positioned supine with neck moderately extended, and a bite block is placed to open the mouth. A small gauze square is placed to protect the submandibular ducts, after which the tongue is retracted out of the mouth using a stay suture (Fig. 1A). The tongue surface and pharynx are painted with chlorhexidine 0.13%. A 70-degree endoscope is placed transorally and used to both elevate the soft palate and simultaneously visualize the hypertrophic lingual tonsils (Fig. 2A). Then, 1% lidocaine with epinephrine is infiltrated into the submucosal tissue of the tongue. Under endoscopic guidance, radiofrequency energy is applied via a Coblation EVac-70 Xtra Plasma wand at setting 9 (ArthroCare ENT, Sunnyvale, CA) (Fig. 2B) to cause molecular dissociation of the tissue and completely vaporize it. Tissue is ablated superficially laterally but deeper as the instrument approaches the midline until the vallecula are seen to be unobstructed, at which point the procedure is stopped. Bleeding is stopped with the plasma wand using the cautery setting. After extubation and transfer to a monitored setting for 24 hours, they are discharged home. Follow-up takes place in 2 to 3 weeks after the procedure, at which time the ablated area is visualized to confirm effective healing (Fig. 1B). (A) Pre-operative view of hypertrophic lingual tonsillar tissue. (B) Post-operative view showing extent of resection. (A) Pre-operative saggital schematic diagram of lingual tonsillar hypertrophy. (B) Intraoperative instrument positioning for maximal ease of lingual tonsil resection. There has been an evolution of surgical access and techniques for lingual tonsillectomy. Safety and success rely on conscientious efforts to ensure good preparation, airway security, optimal exposure for visualization, and resection techniques.1 The history of lingual tonsil resection techniques have progressed from the use of sharp dissection, suction diathermy, laser, microdebrider, cryotherapy, and ultrasonic coagulating dissector to most recently, radiofrequency ablation.1-4 Cold techniques can be associated with significant intraoperative bleeding often resulting in an unclear operative field and early termination of the surgery.2, 4 Hot techniques such as sucti