Coblation vs Microdebrider Intracapsular Tonsillectomy

[Dr. Gopi Shah]
That's cool. In terms of techniques, I know there's microdebrider, there's the Coblation device. What are the different techniques out there and what do you like to use?

[Dr. Kevin Huoh]
I think the one that was earliest described by Dr. Kotai was a microdebrider. That's what I initially learned during my fellowship.

[Dr. Gopi Shah]
Those bleed. [chuckles]

[Dr. Kevin Huoh]
Yes, so they do.

[Dr. Gopi Shah]
That's how I learned. I was like, "What is this?"

[Dr. Kevin Huoh]
It's kind of a bloodbath, right?

[Dr. Gopi Shah]
Yes. It is.

[Dr. Kevin Huoh]
You take a specially designed tonsil blade and you set it I think at 1,500 rpm on your microdebrider machine. Then you just go at it. The tonsil is a big polyp, so you just go at it. What happens is it bleeds, and then you have to use a suction bovie to kind of to cauterize the base.

[Dr. Gopi Shah]
Yes. You're charring everything.

[Dr. Kevin Huoh]
Then by charring everything, you're almost defeating the purpose of reducing pain because you can get the diffusion of thermal energy when you're trying to char the whole tonsil bed. That's where I started with in practice, but I quickly changed to the Coblator. My partner, Nguyen Pham, learned the Coblator method during fellowship. We did the same fellowship, but he just learned from someone else.

The Coblator is what I use now. There's several wands that you can choose to do an intracapsular tonsillectomy. I use a Procise Max Wand. The Procise XP, I think, is a good one for beginners. When I have residents starting out with me, sometimes I'll reach for the Procise XP. It's less aggressive. The active area is smaller than the Procise Max. It's just a little bit slower. I'm all about speed for tonsillectomy.

Then the new product they have out is the Halo Wand, which is very promising. I've used it now for a few months. It's very promising addition to the Coblator system. That uses a different console. For the old ones, a Procise XP or Max, I'll use a setting of seven for Coblate and three for Coag. I'll just start at the medial aspect of the tonsil. For the left tonsil, I'll hold the wand in my right hand, so kind of opposite of what you would do for a bovie, and then start from medial to lateral. Then basically you want the tonsil bed to look like a total tonsillectomy except you have some tonsil tissue left, and that's when you know you're done.

[Dr. Gopi Shah]
You're definitely going more lateral than just the pillars?

[Dr. Kevin Huoh]
Correct.

[Dr. Gopi Shah]
When I think of tonsils, they're not just like round globes. I feel there's some areas that are a little bit more that frowned out a little bit, more lateral. You just have to know the plane that you're looking for to know how deep you want to go. What does it look like? Does it look lacy? Somebody used to tell me that it should look a little bit lacy or something.

[Dr. Kevin Huoh]
When you use a microdebrider, you start seeing more, I guess, lacy or thicker fibers. When you use a Coblator, it's a little harder. I think it looks more striated. You're not looking at muscle, but it starts to look more striated, more fibrous. Tonsil tissue itself is squishy, soft, that whitish stuff. When you're looking at more striated-type tissue appearance, then you know you're getting close to the capsule.

I always tell my residents it's fine to leave a little bit of extra tonsil tissue. I'd rather them do that than dig a hole into the pharyngeal wall. It's not a rocket science. I know that's the most common question I get asked. It's how do you know when you're done? Any surgeon who's done enough total tonsillectomies, you kind of have a feeling. When you get that scooped out concave appearance, you know like, "All right, I'm done."

I would encourage surgeons to follow the regrowth rate. You know we always encourage surgeons to follow your bleed rate. You don't have to follow your bleed rate anymore, I'll tell you that, but you should follow your regrowth rate. That will inform you on whether you're doing enough.

[Dr. Gopi Shah]
Just to get a little bit more granular into the technique, one, in terms of your preference. Do you like a red rubber, not a red rubber to lift up your soft palate?

[Dr. Kevin Huoh]
I do. I use two red rubber catheters, actually. I don't know if that's super common.

[Dr. Gopi Shah]
I think I do too as well.

[Dr. Kevin Huoh]
A lot of my partners use one. [crosstalk]

[Dr. Gopi Shah]
It just depends on the mouth.

[Dr. Kevin Huoh]
A lot of my partners use one.

[Dr. Gopi Shah]
It just depends on your exposure. I use one, too. Some people don't. That's why I asked. Again, this is 10, 15 years later. With the Coblator, the way I had learned was literally you're just lopping it off. What you're describing is with your wand lateral and just taking it down. Letting it melt through the-- [crosstalk]

[Dr. Kevin Huoh]
Medial to lateral.

[Dr. Gopi Shah]
Medial to lateral.

[Dr. Kevin Huoh]
Medial to lateral. You tap it. You just keep on tapping. You literally keep on tapping that tonsil or kind of scoop that tonsil. You don't want to stay on it too long because then you'll char it. You just tap, tap, tap, tap. A lot of people have used a Coblator for other things. I know it's probably for JNAs or other nasal masses. It's a similar thing.

[Dr. Gopi Shah]
Use the tip. How do you deal with clogging? Do they clog in the hole or is the Procise suction hole bigger than the slower XP wand?

[Dr. Kevin Huoh]
Early on, that was a problem for me. The way I've eliminated that is you have to remember, you have to turn up your suction. We have a [unintelligible 00:27:08]. I put it at like 250 to 300. The suction has to be pretty high. Your saline flow has to be pretty brisk. It's all reliant on that repetitive tapping motion. Just not staying on a tissue too long. Then, in my other hand, I hold a suction, actually. You can do a hurd or a suction.

[Dr. Gopi Shah]
I was going to ask you, is it a hurd?

[Dr. Kevin Huoh]
You can start with the hurd. That's what I first started with. Then one of my residents who is now one of my partners said, "Hey, why don't we hold a suction in the other hand?" I'm like, "Yes. It's a great idea." I can manipulate the tonsil with the suction, and it suctions all that excess saline from the oropharynx. I hold a suction in my other hand, and then it tends to work well.

[Dr. Gopi Shah]
Just a regular Yankauer, like the metal tonsil Yankauer suction?

[Dr. Kevin Huoh]
Yes. The metal one. I think [unintelligible 00:28:06] tip vascular suction, I think is the correct name. Some people hold a plastic Yankauer too, but I don't like those. I think they're too big.

[Dr. Gopi Shah]
They're kind of big. Then let's say, do you then have to go over and Coblate the whole area? You know how sometimes when you do a bovie tonsillectomy, then you're like, "Okay." You sometimes need to start-- Do you have to do that or just what's bleeding? Do you do that with vessels you may come across or what is that?

[Dr. Kevin Huoh]
I actually coagulate the whole tonsil that remains, the capsule. It doesn't take very long, but I think that might be why our regrowth rate is lower. Similar to when you're using a suction bovie on the adenoids, you just have a bed of charge sometimes, and that's what we have. You just use a Coag setting on the Coblator device and go over the whole bed.