Can Intracapsular Tonsillectomy Be an Alternative to Classical Tonsillectomy? A Meta-analysis

Abstract

Objective

Tonsillectomy is the most common operation performed in the otolaryngologic fields. Efforts have been made to reduce postoperative complications, and one of these is intracapsular tonsillectomy and adenoidectomy (ICTA), which leaves the tonsillar tissue with tonsillar capsule. This study aimed to evaluate intracapsular tonsillectomy compared with classical extracapsular tonsillectomy in terms of efficacy of the technique for managing obstructive sleep apnea (OSA) and reducing postoperative complications.

Data Sources

We performed a literature search using PubMed, EMBASE, and the Cochrane Library through December 2016.

Review Methods

Summarized risk ratio (RR), risk differences (RDs), and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated by summarizing the risk estimates of each study using random-effects models that considered both within- and between-study variations.

Results

Our search included 15 randomized controlled studies. The RRs for postoperative bleeding and residual tonsils were, respectively, 0.44 (P = .01) and 6.02 (P = .0002). There were significant differences in postoperative pain (P = .0022), need for analgesics (P < .0001), days to normal diet (P = .006), and days to normal activity (P < .00001) between intracapsular tonsillectomy and extracapsular tonsillectomy.

Conclusions

Intracapsular tonsillectomy can effectively reduce postoperative pain and bleeding, which shortens the time required to return to normal life. There was no difference between microdebrider and coblator in intracapsular tonsillectomy regarding postoperative pain and bleeding. It can increase the risk of remnant tonsils; however, it does not increase the risk of recurrent infection.

Keywords

surgical procedures tonsillectomy intraoperative complications postoperative complications intracapsular tonsillotomy

Tonsillectomy is one of the most frequent operations performed in the otolaryngologic fields. Complications include pain, bleeding, dehydration, poor oral feeding, and tonsillar regrowth. Classical tonsillectomy means total removal of the tonsillar tissue with the tonsillar capsule. Large vessels around the tonsillar capsule have to be ligated or electrocauterized when performing extracapsular tonsillectomy and adenoidectomy (ECTA). These procedures result in severe postoperative pain, whereas intracapsular tonsillectomy and adenoidectomy (ICTA), which spares the tonsillar capsule, may cause less pain and allows rapid recovery.¹ ICTA is a procedure in which the microdebrider shaves away most of the tonsil, leaving a small amount of tonsillar tissue around the tonsillar capsule. The tissue and tonsillar capsule remain as a “biologic dressing,” which protects the pharyngeal muscles overlying the tonsillar fossa.² ICTA is known to reduce postoperative morbidity, especially pain and bleeding; however, the technique is not used in recurrent tonsillitis because of the possibility of residual tonsils.

In addition to recurrent tonsillitis, large tonsils and adenoids may obstruct the pharyngeal airway and induce obstructed breathing during sleep. Adenotonsillectomy is recognized as an effective therapy for snoring and sleep-disordered breathing.¹ The use of ICTA to manage obstructive sleep apnea (OSA) has been reported.^3-5 Therefore, a comparison of ICTA and ECTA with regard to efficacy for managing OSA and reducing postoperative complications is useful.

Since the first systematic review, many reports have discussed the efficacy of ICTA, and this debate is still ongoing.⁶ Bender et al⁷ recently reported that ICTA can leave more residual tonsil than ECTA; however, there is less pain and bleeding with ICTA. Previous meta-analyses by Acevedo et al⁶ and Wang et al⁸ included low-quality studies of observational methodology, and thus an updated meta-analysis of randomized controlled trials is needed. This study aimed to evaluate the ICTA and ECTA procedures in terms of efficacy of the technique for managing OSA and reducing postoperative complications.

Materials and Methods

Search Strategy

Two investigators and a professional librarian developed search strategies for locating all of the relevant studies published to December 2016 in the PubMed, Embase, and Cochrane Library databases. Two authors (S.H.K. and J.S.K.) independently conducted the literature search. The following search routine was used for Medline: (tonsillotomy[All Fields] OR intracapsular[All Fields]) AND (“tonsillectomy”[MeSH Terms] OR “tonsillectomy”[All Fields]). We used similar search words for the other databases.

Selection of Literature

Eligible studies met the following inclusion criteria: (1) studies containing classical tonsillectomy and tonsillotomy procedures; (2) classical tonsillectomy, including extracapsular tonsillectomy using electrocautery, cold knife, or coblator; (3) tonsillotomy, including partial tonsillectomy or intracapsular tonsillectomy using a microdebrider or radiofrequency (coblator) or CO₂ laser; (4) randomized controlled trials; (5) studies containing any of the following primary outcomes: postoperative bleeding, postoperative pain, blood loss, operating time, admission due to bleeding or dehydration, days to normal activity or diet, need for analgesic, or Obstructive Sleep Apnea Survey 18 (OSA-18); and (6) a full-length article that provided sufficient data to enable evaluation of the tonsillectomy vs tonsillotomy. Studies excluded from the analysis were (1) case reports, (2) languages other than English, (3) studies about either tonsillotomy or tonsillectomy but not both, (4) review articles that that did not include original data, and (5) observational trials, including prospective and retrospective studies.

Data Extraction

The data were extracted by 2 reviewers independently. Disagreement in the assessment was discussed until consensus was reached. The following information was extracted from each study: author names, publication year, data on complications such as postoperative bleeding and pain, operating time and amount of intraoperative blood loss, days to return to normal diet and activity, and OSA-18. Dichotomous data included admissions due to dehydration, postoperative bleeding, postoperative nausea and vomiting, recurrent tonsillitis, and residual tonsils. Continuous data included intraoperative blood loss, days to normal activity and diet, need for analgesics, operating time, OSA-18 score, postoperative pain, and quality of life. A subgroup analysis was conducted comparing the 2 commonly used instruments, the microdebrider and coblator.

Methodologic Quality

Trial quality for randomized controlled trials (RCTs) was evaluated according to the methods set out in the Cochrane Handbook for Systematic Reviews of Interventions.⁹ This scale assigns points as follows: selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias. There were 3 types of evaluation results: low risk, high risk, and unclear risk of bias.

Statistical Analysis

We used the Comprehensive Meta-Analysis software (version 2.0; Biostat, Englewood, New Jersey), R statistical software (R Foundation for Statistical Computing, Vienna, Austria), and Cochrane Review Manager (RevMan version 5.3; The Cochrane Collaboration, Oxford, UK) for this meta-analysis. Summarized risk ratio (RR), risk differences (RDs), and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated by summarizing the risk estimates of each study using random-effects models that considered both within- and between-study variations.¹⁰ The random-effects model was appropriate considering the effects from different locations, populations, and heterogeneous research groups. Hedge’s g, which is a variation of Cohen’s d that corrects for biases due to small sample sizes, was used for each primary outcome measure.^11,12 The I² value was calculated to identify between-study heterogeneity. An I² value between 0% and 100% was used to represent the ratio of between-study variance divided by the sum of the within-study and between-study variances.¹³ Between-study heterogeneity was interpreted as absent (I²: 0%-25%), low (I²: 25.1%-50%), moderate (I²: 50.1%-75%), or high (I²: 75.1%-100%).¹⁴ To identify publication bias, we used Egger’s test and identified the degree of asymmetry through funnel plots.¹⁵ Duval and Tweedie trim and fill was also performed to adjust for missing studies and to correct for overall effect size with regard to publication bias.¹⁶

Results

Literature Retrieval

The literature screening process is shown in Figure 1 . According to the preestablished search strategy, 306 articles were identified, with 201 from PubMed, 94 from Embase database, and 11 from the Cochrane Library. After browsing the titles and abstracts, we excluded 230 studies that did not fulfill the inclusion criteria. After eliminating duplicate documents, 48 studies remained. These remaining 48 articles were screened by reading the full text, and 13 documents were excluded (2 insufficient data, 1 duplicate data, 7 no control groups, and 3 review articles). Of the remaining 35 articles, 20 documents were excluded due to methodology (5 nonrandomized prospective studies, 15 retrospective studies). Finally, 15 documents were included in this meta-analysis.

Characteristics of the Studies Included

The studies included in the meta-analysis are listed in Table 1 .^2,7,17-29 A total of 1265 participants were involved in our study: 645 individuals in the ICTA group and 620 individuals in the control group (ECTA). The sample size of individual studies varied from 40 to 300.

Table 1.

Summary of Randomized Controlled Trials Included.^a

Author	Publication Year	Primary Outcomes	ICTA		ECTA		Follow-up Period	Risk of Bias
Author	Publication Year	Primary Outcomes	Number and Instrument	Age, Mean (SD) and Setting	Number and Instrument	Age, Mean (SD) Setting	Follow-up Period	Risk of Bias
Bender et al⁷	2015	Bleeding, need for analgesics, QOL, residual tonsil, PONV	50 D	28.1 (5.6) NA	54 EC, S	24.7 (8.1)	2010-2013	Unclear^b
Chan et al¹⁷	2004	Bleeding, pain, need for analgesics, QOL, days to normal diet, days to normal activity, dehydration, PONV, operating time	27 C	6.4 (2.8)	28 EC	5.9 (2.2)	2001-2002	Unclear^b
Derkay et al²	2006	Bleeding, pain, need for analgesics, blood loss, days to normal diet, days to normal activity, dehydration	150 D	5 [4-7] 2000 rpm	150 EC	5 [4-7] 25 W	2 weeks	Low^b
Sobol et al¹⁸	2006	Pain, need for analgesics, blood loss, days to normal diet, days to normal activity, operating time	38 D	3-7 years 1800 rpm	36 EC	3-7 years	10 days	Unclear^b
Lister et al¹⁹	2006	Bleeding, pain	25 D	5-15 years NA	25 EC	5-15 years 20 W	2 weeks	Low^b
Chang²⁰	2008	Bleeding, pain, days to normal diet, days to normal activity	34 C	6.2 (3.3)	35 C	6.1 (2.9)	2004-2006	High^b
Wilson et al²¹	2009	Bleeding, pain, days to normal diet, days to normal activity, operating time	49 D	6.1 1500 rpm	47 EC	5.8 10 W	2004-2006	Low^b
Ericsson et al²²	2009	Need for analgesics, days to normal diet, OSA-18, recurrent infection	35 RF	4.5-5.5 years NA	32 EC	4.5-5.5 years NA	6 months	High^b
Pruegsanusak et al²³	2010	Pain, need for analgesics, blood loss, days to normal diet, operating time	20 D	6.3 (3.15) 1500 rpm	20 S	6.35 (3.25) NA	2003-2005	Unclear^b
Nemati et al²⁴	2010	Pain, blood loss, days to normal diet, operating time, recurrent infection	38 RF	25.1 (7.3) NA	24 EC	22.3 (8.3) NA	2007-2008	Unclear^b
Korkmaz et al²⁵	2008	Bleeding, need for analgesics, blood loss, recurrent infection, operating time, PONV	40 RF	5.5 (2.6) NA	41 EC	5.8 (2.6) 20-25 W	10 days	High^b
Bitar and Rameh²⁶	2008	Bleeding, operating time, blood loss, pain, days to normal diet, days to normal activity, residual tonsil, dehydration, recurrent infection	77 D	3.76 (1.34)	66 EC	4.53 (1.94)	1-36.2 months	High^b
Densert et al²⁷	2001	Bleeding, pain	22 CO₂	2-9 years	21 EC	2-9 years	2 years	Low^b
Park et al²⁸	2007	Bleeding, pain, PONV, dehydration,	19 EC	2-12 years	21 EC	2-12 years	7 days	Low^b
Hultcrantz et al²⁹	1999	Bleeding, pain, needs for analgesic, operating time	21 CO₂	6 (1.5)	20 EC	6 (1.5)	1 year	Low^b

Abbreviations: C, coblation; CO₂, CO₂ laser; D, microdebrider; EC, electrocautery; ECTA, extracapsular tonsillectomy and adenoidectomy; ICTA, intracapsular tonsillectomy and adenoidectomy; NA, not available; PONV, postoperative nausea and vomiting; OSA-18, Obstructive Sleep Apnea Survey 18; QOL, quality of life; RF, radiofrequency; S, scissors; W, Watt (unit of electric power).

Age: mean (SD), median [interquartile range].

Cochrane risk of bias tool.

Risk of Bias

Risk of bias was evaluated in RCTs included. RCTs were evaluated using the Cochrane risk of bias tool. Among the 15 RCTs included, 4 had a high risk of bias, 5 had an unclear risk, and 6 had a low risk of bias ( Figure 2 ).

Intraoperative Findings

There were 9 sets of data reporting length of operating time for ICTA and ECTA, and SMD plus 95% CI were used to evaluate the effect size of operating time for ICTA and ECTA. The summary effect of the 7 studies showed no statistically significant difference in operating time between ICTA and ECTA (SMD, −0.36; 95% CI, −1.02 to 0.30; P = .28) ( Figure 3A ). The result of the heterogeneity test was I² = 93% (P < .001), indicating a high degree of heterogeneity among the studies. Egger tests were not performed due to the small sample sizes in the selected studies.

There were also 7 sets of data reporting intraoperative blood loss for ICTA and ECTA, and SMD plus 95% CI were used to evaluate the effect size of intraoperative blood loss for ICTA and ECTA. The summary effect of the 7 studies showed no statistically significant difference in blood loss between ICTA and ECTA (SMD, −0.88; 95% CI, −2.01 to 0.25; P = .13) ( Figure 3B ). The result of the heterogeneity test was I² = 96% (P < .001), indicating a high degree of heterogeneity among the studies. Egger tests were not performed due to the small sample sizes in the selected studies.

Postoperative Complications

Primary outcomes with regard to postoperative complications are pain, bleeding, nausea, and vomiting (PONV); admission due to dehydration; residual tonsils; and recurrent tonsillitis.

In total, 12 studies reported postoperative bleeding after ICTA and ECTA, and RR and 95% CI were used to evaluate the effect size of postoperative bleeding after ICTA and ECTA. The summary RR showed a lower risk of bleeding after ICTA than after ECTA (RR, 0.44; 95% CI, 0.23-0.85, P = .01). The heterogeneity test showed I² = 0%, indicating no heterogeneity among the studies ( Figure 4A ). Egger tests were not performed due to the small sample sizes in the selected studies.

There were 7 sets of data reporting postoperative pain, and SMD plus 95% CI were used to evaluate the effect size of postoperative pain between ICTA and ECTA. The summary effect of 7 studies showed a statistically significant difference in postoperative pain between ICTA and ECTA with a high degree of heterogeneity between the studies (I² = 83%) (SMD, −0.81; 95% CI, −1.32 to −0.29; P = .0022) ( Figure 4B ). Egger tests were not performed due to the small sample sizes in the selected studies.

Analysis of PONV between ICTA and ECTA revealed no statistically significant difference between the 2 techniques. The summary RD was −0.06 (95% CI, −0.25 to 0.12; P = .50) with a moderate degree of heterogeneity between the studies (I² = 74%) ( Figure 4C ). Egger tests were not performed due to the small sample sizes in the selected studies.

There were 4 sets of data to evaluate the effect of admissions due to dehydration. Analysis of the admissions due to dehydration revealed no statistically significant difference between ICTA and ECTA. The summary RD was −0.01 (95% CI, −0.04 to 0.02; P = .52) with no heterogeneity between the studies (I² = 0%) ( Figure 4D ). Egger tests were not performed due to the small sample sizes in the selected studies.

There were 3 sets of data reporting residual tonsils after ICTA and ECTA, and RR plus 95% CI were used to evaluate the effect size of residual tonsils after ICTA and ECTA. The summary RR was 6.02 (95% CI, 2.35-15.44; P = .0002) with no heterogeneity between the studies (I² = 0%) ( Figure 4E ). Egger tests were not performed due to the small sample sizes in the selected studies.

There were 3 sets of data reporting recurrent tonsillitis after ICTA and ECTA, and RD plus 95% CI were used to evaluate the effect size of recurrent tonsillitis after ICTA and ECTA. The summary RD was 0.00 (95% CI, −0.05 to 0.06; P = .89) with no heterogeneity between the studies (I² = 0%). The summary effect showed no statistically significant difference in recurrent infection between ICTA and ECTA ( Figure 4F ). Egger tests were not performed due to the small sample sizes in the selected studies.

Days to Normal Life

Primary outcomes with regard to days to normal life include days to normal diet, days to normal activity, and need for analgesics.

In total, 4 studies reported days to normal diet after ICTA and ECTA, and SMD and 95% CI were used to evaluate the effect size of days to normal diet after ICTA and ECTA. The summary SMD showed a statistically significant difference between ICTA and ECTA (SMD, −1.27; 95% CI, −2.17 to −0.37; P = .006). The heterogeneity test showed I² = 91% (P < .05), indicating a high degree of heterogeneity among the studies ( Figure 5A ). Egger tests were not performed due to the small sample sizes in the selected studies.

There were 3 sets of data reporting days to normal activity after ICTA and ECTA, and SMD plus 95% CI were used to evaluate the effect size of days to normal activity after ICTA and ECTA. The summary SMD was −0.87 (95% CI, −1.24 to −0.49; P < .00001) with a moderate degree of heterogeneity among the studies (I² = 60%) ( Figure 5B ). Egger tests were not performed due to the small sample sizes in the selected studies.

Analysis of the need for analgesics after ICTA and ECTA revealed a statistically significant difference between ICTA and ECTA. The summary SMD was −0.59 (95% CI, −0.77 to −0.41, P < .0001) with no heterogeneity among the studies (I² = 22.9%) ( Figure 5C ). Egger tests were not performed due to the small sample sizes in the selected studies.

Sleep Index and Quality of Life

There were three sets of data reporting on OSA-18, and SMD plus 95% CI were used to evaluate the effect size of OSA-18. The summary SMD was 0.03 (95% CI, −0.29 to 0.35; P = .87) with no heterogeneity among the studies (I² = 0%). The summary effect showed no statistically significant difference in OSA-18 between ICTA and ECTA ( Figure 6A ). Egger tests were not performed due to the small sample sizes in the selected studies.

There were 3 sets of data in total reporting on quality of life after ICTA and ECTA, and SMD plus 95% CI were used to evaluate the effect size of quality of life after ICTA and ECTA. The summary SMD was −0.85 (95% CI, −2.23 to 0.53; P = .22) with a high degree of heterogeneity among the studies (I² = 95%). The summary effect showed no statistically significant difference in quality of life between ICTA and ECTA ( Figure 6B ). Egger tests were not performed due to the small sample sizes in the selected studies.

Publication Bias

Egger’s regression test was not performed for all of the 13 primary outcomes. In a funnel plot of primary outcomes, the effect size of the studies included (RR or RD or SMD) using Duval and Tweedie’s trim and fill to adjust the potentially unpublished reports did not change significantly, suggesting little publication bias ( Table 2 ).

Table 2.

Effect Size of Included Study and Corrected Effect Size Using Duval’s Trim-and-Fill Method.^a

	Precorrection				Correction Using Duval’s Trim-and-Fill Method				Corrected Study
	Effect Size	95% CI Lower	95% CI Upper	P Value	Effect Size Corrected	95% CI Lower	95% CI Upper	P Value	Corrected Study
Operation time	SMD −0.36	−1.02	0.30	.28	SMD −0.36	−1.02	0.30	.28
Blood loss	SMD −0.88	−2.01	0.25	.13	SMD 0.02	−1.33	1.37	.97	Pruegsanusak et al²³ Nemati et al²⁴
Bleeding	RR 0.44	0.23	0.85	.01	RR 0.44	0.23	0.85	.01
Pain	SMD −0.81	−1.32	−0.29	<.01	SMD −0.81	−1.32	−0.29	<.01
PONV	RD −0.06	−0.25	0.12	.50	RD −0.06	−0.25	0.12	.50
Dehydration	RD −0.01	−0.04	0.02	.52	RD −0.01	−0.04	50.02	.50
Residual tonsil	RR 6.02	2.35	15.44	<.01					Cannot exam due to small sample size
Recurrent tonsillitis	RD −0.00	−0.06	0.06	.99	RD 0.00	−0.05	0.06	.89
Days to normal diet	SMD −1.27	−2.17	−0.37	<.01	SMD −1.27	−2.17	−0.37	<.01
Days to normal activity	SMD −0.87	−1.24	−0.49	<.01	SMD −1.19	−1.63	−0.75	<.01	Wilson et al²¹ Sobol et al¹⁶
Need for analgesics	SMD −0.59	−0.77	−0.41	<.01	SMD −0.49	−0.70	−0.28	<.01	Korkmaz et al²⁵ Hultcrantz et al²⁹
OSA-18	SMD 0.03	−0.29	0.35	.87	SMD 0.04	0.21	0.30	.74	Densert et al²⁷ Hultcrantz et al³⁵
QOL	SMD −0.85	−2.23	0.53	.23	SMD −0.85	−2.23	0.53	.23

Abbreviations: CI, confidence interval; OSA-18, Obstructive Sleep Apnea Survey 18; PONV, postoperative nausea and vomiting; QOL, quality of life; RR, risk ratio; SMD, standardized mean difference.

Left side shows the effect size expressed as RR or SMD. Right side shows corrected effect size using Duval’s trim-and-fill method.¹⁶ All studies apart from “Need for analgesic” show robust and stable outcomes.

Subgroup Analysis of ICTA by Methodology

We performed subgroup analysis on the 2 primary outcomes (postoperative bleeding, postoperative pain) using 2 different techniques (microdebrider, coblator). Postoperative bleeding showed no statistically significant difference between the microdebrider group (RR, 0.43; 95% CI, 0.20-0.91) and coblator group (RR, 0.46; 95% CI, 0.11-1.81) ( Figure 7A ). Postoperative pain also showed no statistically significant difference between the microdebrider group (SMD, −1.20; 95% CI, −2.38 to −0.03) and coblator group (SMD, −0.71; 95% CI, −1.70 to 0.27) ( Figure 7B ).

Discussion

This review aimed to make an overall comparison of ICTA and ECTA procedures. Primary outcomes of complications are bleeding, pain, nausea and vomiting, dehydration, residual tonsils, and recurrent infection. We categorized intraoperative blood loss and operating time as intraoperative findings. We categorized need for analgesics, days to normal diet, and activity into days to normal life. Finally, apnea-hypopnea index, OSA-18 score, and quality of life were categorized into sleep index and quality of life.

This study showed no relationship between intraoperative blood loss and operating time (Figure 3A,B). Although these indicators are affected by the skill of the surgeon, this study aimed to evaluate the difference between the 2 surgical approaches.

Of the postoperative complications, pain and bleeding were significantly reduced in the ICTA group compared with the ECTA group. ICTA reduced the risk of bleeding by 56% compared with ECTA. Since the tonsillar capsule is left intact during ICTA, the underlying vulnerable arteries and nerves are not exposed; therefore, the risk of patients developing postoperative bleeding or experiencing uncontrolled pain is reduced with this procedure.⁷ The tissue interposed between tonsil and tonsillar musculature acts as a barrier and reduces thermal damage to the muscle created by the electrocautery.^1,2 Postoperative pain is due to damage to the tonsillar fossa musculature. However, during preservation of the tonsillar capsule, a small amount of tonsillar tissue may be preserved, and this may lead to a residual tonsil. Our study has found that ICTA may have a 6.02-fold higher risk of development of a residual tonsil than ECTA. This residual tonsil may cause recurrent tonsillitis and act as an infection source when the patient experiences upper respiratory infection or viral infection. However, this meta-analysis showed that recurrent tonsillitis is no higher in the ICTA group than in the ECTA group.

Dehydration is another complication after tonsillectomy. This may result in postoperative pain, nausea and vomiting, and poor oral feeding. Poor oral feeding and postoperative pain can cause dehydration, and this induces a vicious cycle. In this trial, ICTA was found to have no effect on reducing admissions due to dehydration. ICTA also had no effect on reducing PONV.

Postoperative complications may be an obstacle to returning to normal life. Postoperative pain is the main obstacle to returning to normal diet and activity.^2,20 Some authors report that ICTA has an advantage in the resumption of normal dietary intake but has no effect on resolution of pain or returning to normal activity.¹⁸ Koltai et al¹ reported that ICTA can retain tissue as a surgical barrier, resulting in less postoperative pain and with a rapid return to normal activity and diet. This meta-analysis showed that ICTA resulted in less need for analgesics and led to a rapid return to normal activity and diet.

Tonsillectomy may be an effective treatment for pediatric and adult patients with OSA and large tonsils.^30,31 Although the gold standard for diagnosis of OSA is polysomnography, there was no randomized controlled trial regarding the apnea-hypopnea index. There are many reports of subjective measurements, such as the OSA-18, for the assessment of clinical relief.^3,32 This OSA-18 questionnaire consists of 18 questions divided into 5 domains: sleep disturbance, physical symptoms, emotional distress, daytime functions, and caregiver concerns. This study showed that there are no differences in OSA-18 between ICTA and ECTA. Sleep apnea is directly related to quality of life and can induce daytime sleepiness and depressive symptoms, which may disrupt general health.^33,34 Objective methods to assess the effect on quality of life from OSA have been developed in several reports.^3,35 This meta-analysis revealed no difference in quality of life between ICTA and ECTA procedures.

We analyzed the subgroup analysis regarding 2 different techniques when we perform ICTA. We found no difference between the microdebrider and coblator technique regarding postoperative pain and bleeding. The other primary outcomes, including operating time, blood loss, OSA-18, etc, did not have enough subgroups divided by microdebrider and electrocautery.

Conclusion

The present review revealed that ICTA can effectively reduce the major complications of tonsillectomy, pain, and bleeding and help in the return to normal diet and activities. There was no difference between microdebrider and coblator in ICTA regarding postoperative pain and bleeding. Although tonsillar remnants may exist after ICTA, no significant infection was noted after this procedure. There appears to be no advantage in using ICTA over ECTA in relation to sleep disturbance and quality of life.

Author Contributions

Jong Seung Kim, substantial contributions to the conception, design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved; Sam Hyun Kwon, substantial contributions to the conception, design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved; Eun Jung Lee, substantial contributions to the conception, design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved; Yong Joo Yoon, substantial contributions to the conception, design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

Footnotes

No sponsorships or competing interests have been disclosed for this article.

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