Radiofrequency volume tissue reduction of the tonsils: case report and histopathologic findings

Ear, Nose & Throat Journal, August, 2004 by Alyssa R. Terk, Steven B. Levine

Abstract

Innovative new techniques to resect tonsillar tissue have been described in the recent literature. We report the case of a patient who underwent volume reduction of tonsillar tissue by radiofrequency energy under local anesthesia in an office setting. Treatment resulted in a reduction of tonsillar size with minimal pain, which can be attributed to the avoidance of mucosal interruption. The patient subsequently underwent standard tonsillectomy, which allowed us to examine the histopathology of the tissue that was treated with radiofrequency. In doing so, we noted an absence of fibrosis and preservation of normal histologic architecture. We conclude that performing volume reduction of tonsillar tissue by applying radiofrequency energy to the stroma of the tonsils without temperature control results in objective improvement in airway size with minimal effects on the histopathology of the tonsillar stroma. Mucosa-sparing tonsillar reduction may be a preferable alternative to other techniques of tonsillar reduction, especially./'or young children, who would experience a nearly pain-free procedure.

Introduction

Hypertrophy of the palatine tonsils can lead to upper airway obstruction in children and adults and is an indication for surgery. Three procedures have been described to address this common otolaryngologic problem: (1) complete excision of the tonsils by dissection of the tonsillar capsule from the adjacent parapharyngeal muscles (tonsillectomy), (2) near-total removal of the tonsils with preservation of the tonsillar capsule and a small amount of lymphoid tissue (subtotal or supracapsular tonsillectomy), and (3) reduction of the lymphoid elements of the tonsils with preservation of the overlying mucosa (tonsil reduction or volume tissue reduction of the tonsils).

Mucosa-sparing tonsillar tissue reduction has been proposed as an alternative to total and subtotal tonsillectomy. Radiofrequency volume tissue reduction (RF-VTR) makes use of the application of current density around the electrode tip to destroy tissue. Over a period of 4 to 6 weeks, the treated area contracts and the total tissue volume is reduced. (1) Three examples of radiofrequency devices:

* Somnus(Gyrus ENT Division; Memphis, Tenn.) operates at 460 kHz and has a temperature-control sensor.

* ENTec Coblator (Arthrocare; Sunnyvale, Calif.) operates at 100 kHz at an effective temperature of 60[degrees] to 100[degrees]C.

* Ellman Dual-Frequency IEC-II (Ellman International; Hewlett, N.Y.) uses radiofrequency energy at 4.0 MHz in monopolar mode and 1.7 MHz in bipolar mode.

Nelson introduced RF-VTR of the tonsils with the Somnus radiofrequency generator. (2,3) He used a specially designed monopolar needle probe that limits the heating of surrounding tissues by continuously monitoring and controlling the temperature of the treated tissue. The results of his studies in adults were promising, as he reported an average increase in airway size of 1.2 cm. Patients were treated in an office setting, and most returned to pretreatment activity within 1 or 2 days. Tissue continued to shrink over the ensuing 12 weeks, and at the l-year follow-up, airway size remained stable. Complications and postoperative pain were minimal. Nelson speculated that this was perhaps attributable to the lack of disruption of the mucosa, capsule, and the glossopharyngeal and vagal nerve fibers in these tissues.

In this article, we describe the case of an adolescent who was treated with the submucosal application of radiofrequency to the deep stroma of the tonsillar tissue in order to reduce tonsillar size. The patient later required a full excision of the tonsils, which allowed us the opportunity to examine the effect that RF-VTR had on tonsillar histopathology and architecture.

Case report

A 16-year-old girl was referred by an oral-maxillofacial surgeon to the senior author (S.B.L.) for management of hypertrophic tonsils before she was to undergo maxillomandibular surgery to correct a bite deformity. The patient had no complaints or history of sore throat, snoring, or difficulty swallowing. Given the lack of symptoms and the goal of adequately reducing the tonsils in preparation for the corrective orthognathic surgery, she accepted our offer to perform RF-VTR of the tonsils rather than standard tonsillectomy. She ultimately underwent this procedure twice.

Photographic documentation of the oral cavity and oropharynx before and after both procedures was performed in a standard and uniform manner. The tip of the same 4.0-mm, 0[degrees] nasal endoscope was placed between the maxillary central incisors. The images were captured with the same video camera system and printed by the same Polaroid printer. With a tongue blade on the central portion of the tongue, the patient was asked to phonate in order to tense the oropharyngeal musculature and medialize the tonsils. Intertonsillar distance was measured at its shortest point (figure 1).

[FIGURE 1 OMITTED]

Local anesthesia was achieved by injecting 2% lidocaine and 1:100,000 epinephrine into the anterior and posterior pillars. The complete procedure was perforated in an outpatient clinic setting, and only analgesics were prescribed.