The “Swiss-cheese Doppler-guided laser tonsillectomy”: a new safe cribriform approach to intracapsular tonsillectomy

Giovedì, 08 Gennaio 2015

B. Palmieri & T. Iannitti & G. Fistetto & V. Rottigni

# The Author(s) 2012. This article is published with open access at

Abstract Outpatient laser ablation of palatine tonsils is a very interesting procedure that has been recently introduced as a routine in head and neck surgery departments. The aim of this study was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium–aluminium–garnet (YAG) la-ser to remove up to 80 % of tonsillar tissue, as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place, thus avoiding any haemorrhagic complication and minimize pain. A total of 20 patients (men, n013; women, n07), aged between 6 and 63, were recruited for the procedure. They were affected by chronic hypertrophic tonsillitis with a recurrent fever and other symptoms that were related to oral inflammation. Among the 20 patients, no serious adverse events, including haemorrhage-related complications, were observed. Treatment was well tol-erated, even in patients displaying an overall low pain thresh-old. No dropout or uncompleted procedure occurred in the present study. Minor complications included sore throat, mod-erate oedema, mild acute pharynx inflammation, slight periton-sillar exudate and local burning. The postoperative pain,measured by Scott–Huskisson visual analogue scale, was be-tween 5 and 40 mm and was easily counteracted by means of external ice packages and nonsteroidal anti-inflammatory drugs, according to the individual patient’s need. During the 12–36-month follow-up patients showed improved symptoms (n=7) and complete recovery (n=13). A relapse episode was observed in two patients. This study supports fibre optic laser neodymium-YAG tonsil surgery, named “cribriform intracapsu-lar tonsillectomy” or “Swiss-cheese laser tonsillectomy”, as an effective alternative to the traditional cold knife approach or electrosurgery. This approach could become the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost–benefit ratio, the precise targeting of the beam across the affected tissues and the short- and long-term recovery.

Keywords Neodymium-YAG laser . Tonsil . Tonsillectomy . Surgery . Head and neck . Inflammation . Pain


Outpatient laser ablation of palatine tonsils is a very inter-esting procedure that has been recently introduced as a routine in head and neck surgery departments [2, 7, 8]. The traditional technique of “cold” dissection was introduced about 100 years ago [12]. Since then, many different techni-ques have been introduced to speed up the operation, keep intraoperative bleeding to a minimum and reduce postoper-ative morbidity. In Krespi and Ling’s [7] case series, laser tonsillar tissue vaporization under local anaesthesia is suc-cessfully reported in 96 % of patients during a 4-year follow-up period. On the other hand, general anaesthesia is required as a routine procedure for laser tonsillotomy or tonsillecto-my, in children affected by chronic inflammation or sleep apnoea. According to some authors [2, 5, 8], during a single  or multiple 15-min sessions, it is possible to remove the infected tonsillar crypts, leaving in place the capsule as well as almost 30 % of the deep tonsillar tissue. In adults, palatine tonsillectomy, with capsule excision for chronic recurrent tonsillitis, is also a classic technique requiring general an-aesthesia with a risk of complications and postoperative pain. Andrews and Latif [1] described a local anaesthesia modifi-cation of Krespi and Ling’s [7] technique using a 40-W CO2 laser emitting focused laser energy through a small-sized handpiece with success in 74 % of cases with very low pain and complication rate. Sedlmaier et al. [10] reported positive results in 183 children operated with 812 nm 13 W infrared laser diode on an outpatient basis. No bleeding after the procedure was observed. Reichel et al. [9] compared 64 children with recurrent tonsillitis, who had undergone total blunt dissection tonsillectomy and 49 children with tonsillar hyperplasia without tonsillitis, who had undergone partial tonsillectomy with CO2 laser. This study has shown that tonsillotomy with CO2 laser technique is an effective surgical procedure with a long-lasting effect in patients with tonsillar hyperplasia. The benefits over conventional tonsillectomy are a lower risk for postoperative haemorrhage, reduced postop-erative morbidity and accelerated recovery. Therefore, the procedure should be recommended for infected tonsils and might be an option in some patients with mild symptoms of recurrent tonsillitis. Huber et al. [4] described the use of argon laser needle delivery in tonsil hyperplasia surgical treat-ment in 15 children in comparison with historical CO2 laser approach. No haemorrhage was reported, oral food intake and swallowing were normal and postoperative pain was low especially in the third postoperative day favouring argon laser treatment.

Following tonsillectomy, immediate hospital readmission is mandatory in case of secondary bleeding, and an intensive care unit should intensively take care of the patient and, potentially, radiological embolization of the vascular bleeding network might be a lifesaving choice [11]. Positive results have also been previously reported by Ericsson et al. [3] who compared the effects of partial tonsil resection using a radio-frequency technique in 92 children with total tonsillectomy. A follow-up after 1 and 3 years showed that removing only the protruding parts of the tonsils produces the same beneficial long-term effect on recurrent throat infections, if compared to total tonsillectomy. A further study compared the long-term effects of intracapsular partial tonsillectomy using CO2 laser technique and traditional blunt dissection tonsillectomy in 41 children aged between 9 and 15 (n (CO2 laser) 021); n (traditional blunt dissection tonsillectomy)020) [6]. Six years after the procedure, they were asked to answer ten questions about the results of the procedure. The findings from this study showed that partial tonsillectomy represents a reliable method with the same positive long-term effects of traditional treatment.


The aim of this article was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium–alumini-um–garnet (YAG) laser to remove up to 80 % of tonsillar tissue as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place avoiding any haemorrhagic complication and pain.

Materials and methods

A total of 20 patients (men, n013; women, n07), aged be-tween 6 and 63 (35.6 ± 3.4; mean±Standard Error of the Mean (SEM)), were recruited to participate in the study and signed the informed consent. They were affected by chronic hyper-trophic tonsillitis with irradiation to the region of the pharynx, without pus or membranous exudate and recurrent fever. The patients included in this study required a low-invasive surgical procedure to overcome chronic recurrent tonsillar infections. Exclusion criteria for the current study were: cardiomyopathy, renal insufficiency, respiratory insufficiency and pregnancy. The present study was performed at the “Poliambulatorio del Secondo Parere” (Modena, Italy) according to the Helsinki Declaration, and local Internal Review Board (IRB) approval was obtained. The 6-year-old patient was given 0.2 mg/kg Valium (Roche, Milan, Italy) intranasally before the beginning of the procedure. The inferior pole of the tonsil was addressed lowering the tongue and addressing the Doppler-equipped fibre optic tip starting from cephalad (Figs. 1 and 2). The patients with hyperactive gag reflexes were addressed with xylocaine spray over the pharynx, plus pretreatment with intramuscular metoclopramide and domperidone. Each pa-tient, comfortably sitting, was injected with 1 ml of 1 % xylocaine with a 28-gauge needle in each tonsil capsule. Before and after the anaesthetic injection, the vascularization of each tonsil was defined by means of a small-sized Doppler probe 404 (Perimed Instruments, Milan, Italy) coupled along the handle tip of the laser and advanced along the axis of the fibre optic before laser beam delivery. This allowed to identify and carefully recognize the vascular network and avoid any major vascular trunk and/or anomaly during the tonsil burn-ing. A fibre 320 µm in diameter and connected with a 1064 neodymium:YAG (Elettronica Valseriana, Bergamo, Italy; Fig. 3) continuous wave laser was used. The laser fluence was 200–400 J/cm2, and the energy output was 10 W. Exposure time was 2–4 s (during channel drill). A minute after the local anaesthesia injection, we started transfixing the capsule with the fibre optic moving up and down along the lymphatic tissue and gradually emptying the tonsil parenchyma by cautious laser heating. We carefully avoided any damage to the previously identified vascular network because the back and forth fibre movement was strictly performed on the trajectory previously explored by the Doppler probe. The procedure required no more than 5– 10 min and was intermittently performed on each side, allowing thermal relaxation of the laser-injured tissue. A total of 20 to 50 laser channels were drilled and their mouths rinsed with iced refreshment; a liquid disinfectant was administered at the end of the operation. Adverse events, including dysphagia, fever and cough were evalu-ated. The patients were discharged from operative chair 10 min after the end of the procedure, with the multi-drilled tonsil surface being carefully inspected. Follow-up examinations were performed at different time points up to 36 months later according to the individual patient’s needs. During the first examination, the general procedure com-pliance and postoperative pain level were recorded by means of Scott–Huskisson visual analogue scale (VAS). In the long run, the number of relapsing throat inflamma-tion episodes was ascertained, and a clinical examination of the tonsils and pharynx was performed to update the impact of the laser procedure. The protocol enclosed a single session followed by further sessions, if required in case of relapse or inflammation. At the follow-up, the patients were divided into two groups (Table 1), i.e. “complete recovery” if their symptoms had completely disappeared or “im-proved symptoms” when an improvement was observed in their clinical situation after the procedure (Table 1). The amount of tonsillar tissue removed was measured by means of application of a silicon imprint attached to a stainless steel cylinder.


A maximum of three sessions was necessary (mean±SEM; 1.55±0.15). Among the 20 patients who participated in the present study, no major untoward effect, including haemor-rhage-related complications, was observed. The vascular network preliminary exploration with the Doppler probe, immediately followed by the laser tip advancement along the vascular tonsil axis, took very few minutes. Treatment was well tolerated even in patients displaying a low pain threshold, and no dropout or uncompleted procedure was noted. The back and forth fibre optic movements across the lymphatic tissue and far enough from the vascular network created multiple empty channels (between 30 and 120) without completely collapsing the structure. Minor compli-cations are summarized in Table 1. General discomforts, such as cough, pruritus, dysphagia and dryness, were also common among the patients (Table 1). The summary of postoperative pain in the 7 days following the first session, as measured by Scott–Huskisson VAS, was 21.5 ± 2.2 mm (mean ± SEM; range 5–40 mm) and easily counteracted by means of ice packages applied around the neck, nonsteroidal anti-inflammatory drugs and other drugs according to the individual patient’s need (Table 1). Dur-ing the 12–36-month follow-up patients showed im-proved symptoms (n=7) and complete recovery (n=13). A relapse episode was observed in two patients. The procedure was safe since no serious adverse events, including haemorrhagic complications, occurred. The pain perceived was of low intensity, and after the proce-dure, the patient was allowed to drink and eat without any further complications.

Table 1 Summary of study results                    
Patient number    Age    Diagnosis    Sessions*    Adverse events    Postoperative pain (VAS, mm)    Follow-up**
                    measured in the 7 days following    
                    the first session (medication used)    
1    24    Chronic tonsillitis    1    /    20        24 months/Improved symptoms
2    57    Hypertrophic tonsillitis    2    Moderate sore throat    10        18 months/Complete recovery
3    34    Recurrent tonsillitis    3    Moderate burning    20        36 months/Complete recovery
                and local swelling            
                persisting for 24 h            
4    37    Chronic pharyngotonsillitis    3    /    25        16 months/Improved symptoms
5    26    Relapsing acute tonsillitis    1    /    5        21 months/Complete recovery
6    27    Tonsil remnants with infections    2    /    15        24 months/Complete recovery
7    24    Tonsillar hypertrophy    1    Moderate oedema    20        16 months/Complete recovery
        and infections                    
8    56    Recurrent tonsillitis    1    Moderate burning    40    (Diclofenac 100 mg capsules    21 months/Complete recovery
                persisting for 48 h    [2 times/day for 3 days; IBSA,    
                    Lugano, Switzerland])    
9    21    Relapsing tonsillitis and    1    Moderate exudate    30    (Naprosyn 750 mg capsules,    20 months/Complete recovery
        tonsillar hypertrophy            [2 times/day for 3 days;    
                    Recordati, Italy])    
10    6    Tonsillar hypertrophy    2    Moderate pain    20    (ice)    24 months /Complete recovery
                and dysphagia            
11    32    Pyogenic tonsil remnants    2    Pain and scanty    40 (Tranex, 500 mg/5 ml ampoules    20 months/Complete recovery
                blood spots    [2 times/day for 1 day; Malesci Istituto    
                    Farmacobiologico, Bagno a Ripoli,    
                    Italy], Contramal 100 mg capsules    
                    [1/day for a day; Formenti, Milan, Italy])    
12    51    Tonsillar hypertrophy and    1    Burning and pruritus    20    (ice)    18 months/ Complete recovery
        relapsing tonsillitis                    
13    19    Relapsing tonsillitis    2    Moderate discomfort    15    (Ephynal 300 mg capsules    15 months/Improved symptoms
        and laryngitis        and dryness    [3 times/day for 2 weeks; Abiogen    
                    Pharma, Pisa, Italy] and ice)    
14    63    Post-viral tonsillar    1    /    5        19 months/ Improved symptoms
15    34    Chronic tonsillitis    1    Moderate discomfort    20    (ice)    12 months/Improved symptoms
                and cough            
16    44    Tonsillitis and tonsillar    2    /    30    (Toradol 30 mg/ml ampoules    18 months/Complete recovery
        hypertrophy            [1/day for 2 days; Rome, Italy])    
17    43    Chronic fibrinous tonsillitis    1    Some transient    25    (ice)    14 months/Improved
                dysphagia            symptoms but one replapsing
                            episode was observed
18    59    Acute relapsing tonsillitis    1    Sore throat    10        18 months/Complete recovery
19    34    Tonsillar hypertrophy    1    Slight oedema and    25    (local Xentafid 0.13 % [3 times/day    24 months/Complete recovery
        and rheumatic fever        swallowing burns    for 5 days; Fidia Farmaceutici, Abano    
                    Terme, Italy] and ice)    
20    21    Waldeyer’s hypertrophy and    2    Inflammation of the    35    (Augmentin 375 mg tablets    24 months/Improved
        tonsillar culture positive for        pharynx    [2 times/day for 3 days;    symptoms but one replapsing
        Streptococcus viridians            GlaxoSmithKline,    episode was observed
                    Verona, Italy])    

*    Number of sessions varied according to the individual patient’s clinical situation

**    Follow-up varied according to the individual patient’s clinical situation

The present study describes the use of a Doppler-guided fibre optic neodymium-YAG laser to remove up to 80 % of tonsillar tissue. We named this procedure “cribriform intracapsular tonsillectomy” or Swiss-cheese laser tonsillectomy. This pro-cedure consists in a multi-drilled total or subtotal parenchyma removal, leaving the membrane and vascular stromal network in place. At the 12–36 month follow-up, among 20 patients, 7 patients showed an improvement in symptoms and 13 showed a full recovery. Two patients reported a relapse episode.

 Treatment was well tolerated with no untoward effects. Post-operative pain at day 7 following the first session was between 5 and 40 mm. Therefore, the present approach allows achiev-ing relatively painless removal of tonsillar tissue safely and with promising results.

According to the literature, several tonsillectomy-related complications may occur. Selected tonsillar tissue destruc-tion by a small-sized laser fibre optic is a safer option compared with the traditional cold knife approach or elec-trosurgery. In this article, we describe a procedure that enc-loses a Doppler-assisted neodymium-YAG surgical procedure to identify vascular topography, thus preventing any damage to the vascular network during the fibre optic insertion and, through the capsule, into the affected parenchyma.

We argue that cold knife tonsillectomy is cumbersome and time-consuming, and we suggest to preliminarily explore, step by step, by means of Doppler probe, the tonsillar parenchyma along the fibre optic direction. The procedure is followed by laser parenchyma ablation. In our experience, the creation of multiple channels into the lymphatic tissue was very effective to remove either hyperplastic or chronically infected tonsils, and offered a better quality of life in terms of pain control, immediate swallowing, eating and precocious recovery. As to the laser source, we had preliminary comparative experience with argon, CO2, fibre optic diode and neodymium-YAG laser. Argon and CO2 laser did not reach any substantial advancement in the surgical outcome and were quite cumber-some to be used across the tonsils resulting in relevant pain. The fibre optic innovation opens new perspectives in tonsillar surgery, rendering the procedure very easy and individually tailored to the tonsils’ anatomy and pathology. Our strategy, consisting in coupling Doppler and fibre optic in the same handle, was fundamental to achieve the goal of the procedure without risks. The neodymium-YAG source is the most effec-tive in terms of simple use and energy quality as it is an optimal choice in the operating room. We routinely adopted the 320-μm fibre optic diameter, being the safest possible in terms of minimal damage to the surrounding tissue and the selectivity of minor vessel coagulation. In fact, no haemor-rhage was observed in our cases, and haemostasis was excel-lent and safe due to the previous identification of the major tonsillar vessels and, more generally, to the vascular paren-chymal network. This laser approach, compared with cold knife tonsillectomy, leaves some sterilized necrotic debris and cluster particles that might elicit a better immunological response against infectious agents. It can also explain the long-term successful outcome of the fibre optic procedure extended to the pharyngo-tonsillar area that is very often involved in the inflammatory process. In conclusion, fibre optic laser procedure can be the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost–benefit ratio, precise targeting of the beam across affect-ed tissues and short- and long-term recovery. Conflict of interest The authors certify that there is no conflict of interest with any financial organization regarding the material dis-cussed in the manuscript. This study was performed according to the Helsinki Declaration. Local IRB approval was obtained.

Open Access This article is distributed under the terms of the Crea-tive Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.


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Written informed consent was obtained from the patients for publica-tion of the data included in this manuscript. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Statement of authorship

The authors hereby certify that all work contained in this article is original work. The authors claim full responsibility for the contents of the article. All the authors contributed equally to this work.

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