The National Institute for Health and Clinical Excellence is examining tonsillectomy using laser and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute’s Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about tonsillectomy using laser.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendations
• the identification of factual inaccuracies
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.

The Advisory Committee will then prepare draft guidance which will be the basis for the Institute’s guidance on the use of the procedure in the NHS in England, Wales and Scotland.

• For further details, see the Interventional Procedures Programme manual, which is available from the Institute’s website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 27 April 2006

Target date for publication of guidance: July 2006

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of tonsillectomy using laser appears adequate to support the use of this technique provided that normal arrangements are in place for consent, audit and clinical governance.

Use of tonsillectomy using laser may result in higher rates of haemorrhage than some other techniques, and clinicians wishing to use ultrasound scalpel should be specifically trained. The British Association of Otorhinolaryngologists – Head and Neck Surgeons has agreed to produce standards for training.

Surgeons should ensure that patients or their parents/carers understand the risk of haemorrhage after tonsillectomy using laser. In addition, use of the Institute’s Information for the public is recommended (available from www.nice.org.uk/IPGXXXpublicinfo).

Surgeons should audit and review the rates of haemorrhage complicating tonsillectomy in their own practices and in the context of the techniques they use. Publication of further information about the influence of different techniques and other factors (such as age) on the incidence of haemorrhage after tonsillectomy would be useful in guiding future practice.

Indications for tonsillectomy include recurrent acute or chronic tonsillitis, peritonsillar abscess and pharyngeal obstruction/obstructive sleep apnoea. Life-threatening complications of these conditions are rare, and the main aim of surgery is to relieve symptoms.

For laser tonsillectomy, the tonsil is retracted medially and is then dissected with the laser.

Laser vaporisation tonsillectomy is performed using microscopic control so that around 95% of the tonsils are vaporised in one setting.

Two studies assessed outcomes following laser assisted serial tonsillectomy. Outcomes in both studies were poorly reported.

Most of the Specialist Advisors expressed no concerns about the efficacy of the procedure but noted that postoperative pain was often greater than with other tonsillectomy methods. They also noted that very few clinicians in the UK use lasers for tonsillectomy.

Bleeding is an important complication of tonsillectomy. It can occur intraoperatively, during the first 24 hours after the operation (defined in most studies as primary haemorrhage) or after 24 hours (secondary haemorrhage). Postoperative haemorrhage may require the patient to be readmitted to hospital and possibly undergo further surgery.

In general it was noted that intraoperative blood loss was less with the use of the KTP laser compared with cold steel dissection. Two out of seven studies reported cases of primary haemorrhaging following laser tonsillectomy. In one randomised controlled trial 11% of patients (9/79) had a primary haemorrhage following laser tonsillectomy compared with 6% of patients (4/72) in the cold steel dissection group (difference not significant). In the second study, a UK cases series of 54 patients, two patients (4%) had primary haemorrhages.

In two studies (of 86 and 66 patients), no peri-operative or anaesthesia-related complications, or early or delayed bleeding, were reported following laser assisted serial tonsillectomy. For more details, refer to the sources of evidence (see appendix).

The Specialist Advisors considered that there was a slight increase in postoperative haemorrhage compared with cold steel dissection. They also noted the risk of laser damage to the patient’s face and heat damage to the upper airway.

It was noted that a number of different types of laser can be used.

It was also noted that the National Prospective Tonsillectomy Audit recommended that all surgeons undertaking tonsillectomy should be trained in the use of cold steel dissection and ligature haemostasis, as well as in the use of any electrosurgical techniques.

The Institute has issued guidance on electrosurgery (diathermy and coblation) for tonsillectomy (www.nice.org.uk/IPG150). The Institute is also producing guidance on tonsillectomy using ultrasonic scalpel (www.nice.org.uk/ip_242).

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• Interventional procedure overviewoftonsillectomy using laser, December 2005

  Available from: www.nice.org.uk/ip057overview