Coblation Intracapsular Tonsillectomy with Dr. Elise Graham

In our 27th episode, Pediatric Otolaryngologist Dr. Elise Graham joins us to discuss coblation intracapsular tonsillectomy, a less invasive technique now making its debut in Atlantic Canada. We explore how it compares to traditional approaches, when to use it, and what it means for the future of tonsil surgery.

Show Notes

Kyrollos: Hello everyone, and welcome back to another episode of the Oto Approach. This podcast is created by a team of ENT residents, staff physicians, and medical students to help you prepare for ENT rotations and excel during your clinical experiences. My name is Kyrollos, and I will be your host for this episode. I’ve just wrapped up my first year of medical school at Dalhousie University, in Halifax Nova Scotia.

Today, I have the pleasure of interviewing Dr. Elise Graham, a pediatric otolaryngologist working at the IWK Health Centre. Dr. Graham completed Medical School and Residency at Dalhousie University and then after completing a fellowship in pediatric otolaryngology at the University of Utah, worked as a staff physician for a number of years at Western University before returning to Dalhousie as a staff physician in Halifax. Dr. Graham has an extensive research background in all areas of pediatric otolaryngology, with a focus on airway, infant feeding and swallowing, and breastfeeding. She’s received a great deal of recognition for her studies in these areas, with several awards and honours received for her work.

More recently, Dr. Graham completed the first coblation intracapsular tonsillectomy in Atlantic Canada. A Tonsillectomy is one of the most common surgeries in ENT, especially in children. Traditionally, surgeons have performed what's called a "total" or extracapsular tonsillectomy, where the entire tonsil - including the capsule that surrounds it - is removed. While effective, this approach can cause more postoperative pain and a higher risk of bleeding, because it exposes the raw muscle bed underneath.

In contrast, intracapsular tonsillectomy - also known as partial tonsillectomy - is a newer technique that leaves the tonsillar capsule in place. The bulk of the tonsil tissue is removed, but the capsule acts as a protective barrier, reducing pain and the risk of serious bleeding. Studies have shown that this technique can lead to faster recovery, fewer complications, and less time off school or work - especially in kids. There are several techniques that have been used in intracapsular tonsillectomies such as microdebrider (PITA) or CO2 laser approaches. Even more specifically, coblation intracapsular tonsillectomies use low temperature energy to remove tonsillar tissue without violating the capsule. We will be discussing this approach today.

This technique is already gaining traction across Europe and North America, but here in Atlantic Canada, Dr. Elise Graham is leading the way as the first surgeon to perform it in the region. Today, she’ll tell us why she made the switch, what the learning curve looked like, and what this could mean for patient care going forward.

And I'm with Dr. Graham right now Dr. Graham, thank you so much for taking the time to sit down with me today. 

Dr. Graham: It's my pleasure. 

Kyrollos: So starting off, could you just tell us a little bit about your journey and medicine, and what drew you to otolaryngology specifically? 

Sure. So, initially when I went into medical school, I thought I might want to do OBGYN, which I think is a pretty common thing to draw - well, I think - young women specifically into medicine because it's sort of interested in women's health. And so this seems like a very different place for me to be. I decided in my first year of medical school to try an elective and something completely different, that I didn't think that I wanted to do, and I've had a minor ENT surgery when I was younger. So I tried ENT and I spent the year with Dr. Massoud and I loved it. And so that was a rhinology sort of general elective, and I really liked it a lot. And then I did a few other things. And then when I went back to my first rotation of clerkship, my first surgical rotation of clerkship, I believe was ENT, and when I went back to it, it really felt like home. So I got serious about it just at that point in the early third year. What I liked about it, it has the medical and the surgical aspect to a complete area of the body. So, I mean, it is similar to OBGYN in that way in that you are the medicine, you're the expert in everything medical and everything surgical in your anatomic area. And then I found that I actually really love pediatric otolaryngology. What I liked about OBGYN was the baby, and the baby's not really a big part, actually of OBGYN. So spending more time with, you know, young children and families and building rapport, with families, I really liked. And actually, I've made women's health and women's issues a big part of my research practice or of exploring the experience of women in surgery. And so it's interesting how the things that you like can be shaped into a totally different thing than you expect in your future career. 

Kyrollos: Yeah, it's definitely interesting to see how those different qualities translate between various specialties. I was going to ask you, what about your path through to paediatrics specifically? Was there anything else you wanted to add in terms of that? 

Dr. Graham: I had really strong mentors. So Dr. Hong here at Dalhousie was a research mentor for me and a clinical mentor. And I think I always really knew that I liked interacting with families and with kids, and the anatomy is really exciting. It's a lot more fun to build a rapport, I think. Anybody can examine a grown up's ear, but, you know, build enough of a therapeutic alliance - you can do that in a child and they feel comfortable is pretty special. And then, you know, I've always liked the neonatal and paediatric airway as well. So I find it to be very rewarding - both in the clinical environment and in the OR. So yeah, it was a pretty natural fit for me, plus the family part of it, I really like.

Kyrollos: Yeah, definitely. And obviously, we've already kind of, you've already kind of talked a little bit about your clinical career so far, and we know you have a very extensive research background. But in addition to your clinical career, it looks like you're also having a growing presence in the online medical space. So how did that evolve alongside your career? What was it like opening that up? 

Dr. Graham: I'm a bit delinquent when it comes to that, and sometimes it's more like mommy blog kind of content than it is medical blog kind of content. I like showing people that you can kind of have a life outside of medicine and that, you know, you're a doctor or your staff is a real person in addition to being sort of a faceless medical person. I thought that a lot of my patients were coming in who seemed to be absorbing misinformation. So when I have the, you know, when I've got a moment, I try and generate, you know, useful content that's not, that doesn't contain misinformation or sort of combat misinformation. Although sometimes I find my skin is not quite thick enough for that. So sometimes people don't enjoy content that goes against what they believe or what they themselves are posting. So I try to, you know, I try to make educational content and fun content and also make things that make your doctor a bit more accessible as a person. 

Kyrollos: Yeah, it's definitely good to produce good quality information in a time where there's so much misinformation, especially around various topics in medicine. So it's definitely good to have a growing presence in that area. 

Dr. Graham: I keep trying to do it more and more. And sometimes I get back to it or I'll get inspired about a particular topic and make a post about it. But I think it's important to make it in a way that's, you know, digestible for families, kind of aesthetic. It's a fun creative outlet as well to, you know, make content that looks nice and I enjoy it. I just kind of ebb and flow with it a bit, I would say. 

Kyrollos: And outside of medicine, do you have any other hobbies that you like to get up to? 

Dr. Graham: I'm in a season of life where it's very difficult to have hobbies, so I have three little kids, and I would say I spend my time when I'm not working, trying to spend time with them. So we're really busy. I don't know if anything would be described as a hobby that I currently do. You know, taking kids' places and doing activities and having fun with them by the ocean and stuff like that. So it's very busy. We used to travel. I'm sure we'll get back to that, and we like to travel with the kids. Yeah, it's... There's not a whole lot of space for hobbies at this moment. It's a good thing I like all the things that I do. Yeah. Yeah, definitely. It's good to have some level of balance. 

Kyrollos: Yeah, for sure. So getting into our topic today, which is intracapsular tonsillectomies, just asking about tonsillectomies in general starting off. What are the main clinical indications for choosing a tonsillectomy for a child? 

Dr. Graham: So the most common reason that we take tonsils out now has shifted. It used to be for recurrent strep infections, and now it's much more commonly for sleep disordered breathing or obstructive sleep apnea. So that's the number one indication. We still do some for recurrent strep tonsillitis. We also, you know, there's some other indications, there are softer ones, things like PFAPA, which is a rheumatologic condition, can sometimes benefit from having tonsils taken out peritonsillar abscess, recurrent pe tonsillar abscess - two or more, is usually my criteria. There are other things that you can talk to families about with kind of shared decision making. Sometimes it'll be things like tonsil stones, but I find that a tougher sell from a risk benefit kind of perspective, but the main one is sleep disorder breathing or sleep apnea. 

Kyrollos: Okay. And just following up on that question, on the indications for a tonsillectomy, could you tell us about the difference between an extracapsular and an intracapsular tonsillectomy for our viewers? 

Dr. Graham: So, an extracapsular tonsillectomy is the traditional type of tonsillectomy that you think about, and there's lots of different tools. you can use to do it. Essentially, you take the entire tonsil and the capsule around it. There's a pretty clear plane in most patients where you can see the capsule and you take the tonsil, and with it, the capsule. Intracapsular tonsillectomy is sometimes called a partial tonsillectomy, but the goal is to take as much as you can while leaving the capsule rather behind. You essentially shave or nibble or coblate or whatever tool you use - the tonsil away, but then leave the capsule behind. 

Kyrollos: Okay and what kind of got you familiar with the intracapsular approach in the first place? 

Dr. Graham: So, in my training at Dalhousie, one of my colleagues does intracapsular tonsillectomy using a microbider or microbreer technique. And so I learned that in residency. Everyone develops kind of their favourite way of doing tonsillectomy and mine has always historically been the extracapsular or monopolar tonsillectomy. So I had this in my toolbox, but I didn't really use it past residency. Then I - a couple things - there were some serious complications near, but not at my institution, that may, you know, may or may not have been related to post-tonsillectomy bleeding, which is a common complication of extracapsular tonsillectomy. Around the same time, I went to a great debate style conference talk that one of my colleagues did, and he was on the side of intracapsular tonsillectomy. And his talk really resonated with me. He said, you know, what are the reasons I don't like an intracapsular tonsillectomy? Well, it's a bit annoying. And that's sort of how I felt about it. The good sides of it are a decreased pain, decreased post-op bleeding risk, and improved recovery for patients. And so I thought to myself, geez, am I, why am I not considering this just because it's a bit annoying to me? And then I got the opportunity to try a different tool for it, got some training with it from one of my colleagues at Western. I was at Western for six years prior coming to back to Halifax. And he had more experience during the intracapsular coblation tonsillectomy. And I found I quite liked it. And so it was a bit of a natural transition to using that tool. In my fellowship, I had done some extra capsular tonsillectomy with coblator, and that I do not like at all. I found, you know, it didn't improve my outcomes, and it was, you know, more challenging to find the plane. And so I found initially it was not a tool that I liked, but then trying it for intracapsular, I really liked it a lot. 

Kyrollos: Okay. And I'm glad that you touched on coblation intracapsular tonsillectomy because we're going to talk about that a little bit later. I noticed you mentioned that you found intracapsular tonsillectomy a little bit annoying in the first place. Could you tell us a little bit more about that? 

Dr. Graham: With the microdebrider, it bleeds while you're doing it, and, you know, it's not not torrential or anything that you can't handle, but I just, I didn't like it. I preferred doing the monopolar extra capsular. It was clean. It was usually pretty dry, and I'm fast at it. So, you know, I found that that worked really well in my hands and then I just, I just wasn't loving the microdebrider. That said, I actually am looking at adding that back into my toolbox because I think it's good to have lots of ways to do things. And I do think that it definitely has a role. And again, being a little bit annoying is not a good reason to not do something if it's something that has value to the patient. 

Kyrollos: Definitely. And so is it fair to say, was it the chance to get better postoperative outcomes that kind of drew you to taking on that extra skill, in intracapsular tonsillectomy? 

Dr. Graham: 100%. You know, a post-tonsillectomy bleed is a devastating complication and can, I mean, it's very rare, but it can be a fatal complication. It's terrifying for families. The rate is about 3% to 4% in extracapsular tonsillectomies, no matter how you do them. There are benefits to extracapsular tonsillectomy that I think we should also talk about. But I think if we're taking out tonsils for a healthy child who has sleep disordered breathing, then I think it makes sense to consider doing something that's less invasive and has less risk. It's nice because it, you know, again, less pain, less risk of this bleeding, which can be very terrifying for parents and children. And then also, you know, from my perspective, this is an emergency surgery that in the middle of the night, you know, we could not be doing. So when I have a discussion with family, sometimes I say, you know, there is one thing about the intracapsular technique is there's a 2% risk of revision or regrowth. And so I talk to them about that. You know, we're trading the possibility for doing a second surgery in the future, you know, at two in the afternoon, maybe we're scheduling a revision tonsillectomy. But that's compared to a 3% or 4% risk of a second surgery that happens in the middle of the night on an emergency basis. So I think that that's a favourable trade-off, you know, not having a tonsil bleed surgery, but instead, maybe having a future revision tonsillectomy electively. 

Kyrollos: Yeah, definitely. And it sounds like you're kind of already touching on this, but I wanted to ask, how do you yourself approach counselling and decision making with families when you present ICT as an option? 

Dr. Graham: I think it's important for families to be really informed about it because there are different sets of risks. And it depends on a family's values. Some families are not interested in considering it. They want it to be one and done. So they want the tonsils to be out, gone, and they never want to think about them again. And I think that's reasonable and I respect that. Especially I find families who've had other children that have tonsillectomies, especially if they didn't have a negative experience or if they themselves have had it and they didn't have a negative experience. It's different if they remember a negative experience, then they might be more likely to consider the intracapsular. I would say in kids who have sleep disordered breathing who are otherwise healthy, I express all of the risks, but I'm more likely to suggest that the ICT might be more beneficial in that certain group of patients. If we've got recurrent tonsillitis, data suggests that you can do an intracapsular tonsillectomy, although some people still don't like it. I give them both options in that case. You know, there is a possibility that will have a little bit of residual tonsil that still gets infected. Those are trickier revision surgeries that are scarred and so on. So again, everybody knows about all the options. I tell them the option, I think is slightly more favourable or I, you know emphasize that a bit more. If it's equivocal, I let families decide. You know, I always let families decide, but, you know, I'm less likely to suggest one as being superior to the other. And I do think it's really important that they know about the risk of tonsillar regrowth. And I guess on the same side, you know, children who I think are more likely to have need more surgery for sleep apnea, for example, like a child with Trisomy 21, you might weigh like, you konw, they've got low tone, they've got a macroglossia - a big tongue. There's all these other reasons why they might have persistent sleep apnea afterward. Do I want the question of residual tonsil to be there? So there's an argument to be made for taking them out completely so that people, you know, if you're looking, oh, they still have sleep apnea, should you take the tonsils out again? Well, I'd like to remove that from the equation. Then again, sometimes those are more fragile children. So, you know, it's a bit of a balance and very much shared decision-making kind of thing.

Kyrollos: I'm glad that you kind of started discussing different cases where you might consider doing a different approach other than intracapsular approach. So I wanted to ask, are there actually specific patient populations or comorbidities where ICT is clearly preferred and you have a contraindication to an extracapsular approach or vice versa. 

Dr. Graham: That's a great question. A really good case for a patient to have a coblation intracapsular tonsillectomy would be a kid who has a cochlear plant. So you don't want to use electrocautery around that area. And again, I think the data maybe varies a little bit, but traditional teaching is you don't want to do monopolar cautery around a cochlear implant. And so this is a really excellent option. It has both, you know, the coblate technology and COAG that's bipolar, so it's a very safe instrument for that type of patient. So that would be an example, for sure. 

Kyrollos: Okay. Thank you for that. In terms of your intracapsular tonsillectomy approach, obviously, you were the first surgeon in Atlantic Canada to use the coblator here. So can you just walk us through some of the key steps in that surgery? 

Dr. Graham: There are some colleagues. I have a colleague who likes the Cobator for like ad noidacomy, so I don't think I'm the first to use the coblator. But for intracapsular tonsillectomy, the rumor is that I'm the first in Atlantic Canada to do a coblation intracapsular tonsillectomy. So what I do, it starts out very similar, you know, patient is positioned in the same way. Anesthetic is done pretty much in the same way. In the case of extracapsular tonsillectomy, I usually use - our monopolar doesn't have a smoke evacuator, so I usually use one suction catheter in the nose to suction. And in the coblator, it has a suction built right in. So I use instead the suction catheter to retract the palate forward, which again I don't usually use in a monopolar. There's a difference in there how everyone does their retraction. And then I usually do the left first, which is also the opposite because you use your right hand to do the left tonsil with coblator. and then just gently kind of melt it away. There are a few different hand pieces or wands for the coblator and the one that I like is the PROCISE MAX, the newest one is the HALO, and everyone has their different one that they're comfortable with. The PROCISE MAX is similar to the EVAC70, which is like the early model, which is what I used prior. So, you know, that's the one that I like in my hands, I feel like I'm the most comfortable with it. You shave down until it looks like you're getting close to capsule at that point, it's an important time to slow down. and then at the very base, when it's yellowish, it's no longer bubbling, and it just doesn't look like we're, we're getting any more tonsil away than I coag the complete base of it with the coblator tool. And there's lots of things that are different about that than my technique with the monopolar. For me, with the monopolar, I make my whole line, take them out, and then I don't coag anywhere that doesn't look like it's actively bleeding. For example, where with the coblader, I use the COAG for the entire base. It doesn't create the same type of scab with the bipolar I find, and that was the guidance that I got when I was training to use the coblator. And then I repeat the same procedure on the other side using my left hand and then adenoids as indicated. The one critique I have of the PROCISE MAX wand, it doesn't bend very well, and there's no stylette for it, so sometimes it gets plugged when you do the adenoidectomy, which is very irritating. Again, I don't think it's the end of the world to switch to a suction coagulator if I'm finding that the balance of the amount of time we're taking for the procedure and the plugs, you know, outweighs the minor cost of another instrument. But typically I just do the coblation for the adenoids as well. 

Kyrollos: Okay, and I do remember it getting in one of the times I was with you. 

Dr. Graham: Yeah, so it's not, I mean, the HALO is designed to improve that because it doesn't king as well and has a stylette, but it has a hot surface on the back of it, which I like less. And again, I'm sure with some time I would get comfortable with that tool, but the best tool is the one that feels best and works best in your hands. And so I choose the one that I like the most. 

Kyrollos: Definitely. And just a follow-up question in terms of learning the technique: what was the learning curve like when you learned that technique? Or what would you think the learning curve would look like for trainees who wanted to get more more familiar with this technique? 

Dr. Graham: It is a little tricky to learn. I mean, there are some pitfalls. It's a tool that can cause injury or damage. If you move it in a way that you don't attend to, or you touch a structure that you shouldn't touch. Like you really cause a lot of damage with a coblator. So I think I have a lot of caution with it. Interestingly, I find the extracapsular tonsillectomies to be easier to teach. You know, you can see someone get into the right plane and then they're in it, and I, you know, I wash my trainees very closely and I pay lots of attention, but I can give them a bit more autonomy. For the coblator, I feel that I need to watch right till the very end because the most dangerous part is at the very end when you could go through the capsule. And you know, there's large blood vessels that are beyond the capsule. So I think it's tricky to learn only because it requires the right amount of caution and good hands that don't move where, you don't intend to. So I find it a bit nerve wracking to train people on the coblator, you know, it's important. I just watch them closely. 

Kyrollos: Definitely. That makes sense. Kind of going back to the data that we have on ICTs, there's definitely been a great deal of recent evidence highlighting reduced complication rates like you mentioned. Lower rates of postoperative pain and bleeding. And the recovery time being shorter as well. Have you noticed that shift? Obviously, it's present in the data. When you started doing this approach in comparison to the extracapsular approach, did you notice that shift in your patients?

Dr: Graham: So, I mean, data is still being collected, and as you may know, I came back to Halifax just in January. So I started doing this last year in April at Western and our data looks very favourable so far. And my personal opinion as well, you know, seeing patients afterward and talking to them after they found the pain was much less, and we did see definitely reduced postoperative bleeding. In terms of how long we've been doing it here, we don't really have the data. None of my patients, I'm going to knock on wood. None of my patients have come back yet to complain about it. So I think that's really positive. Again, I think it's important, you know, we talk about it as being a really wonderful technique and it is, but it isn't for everyone, and there are reasons why we choose both. But in the right selected patients, I absolutely love it for the correctly selected patient for sure.

Kyrollos: Okay. And it sounds like you haven't had many patients come back and say that it turned out negatively. 

Dr. Graham: Yeah. Well, when I say come back, they come back to the emerge, right? They come back either with bleeding or with pain. And we're just not getting a lot of that. 

Kyrollos: Yeah. So I guess more in general, when you've done an intracapsular tonsillectomy, what complications have you noticed happened? 

Dr. Graham: So far I've had very, you know, very minimal, again, knock on wood, complications. Like the risk of bleeding is still 0.5%, so there will be bleeding. You can also have intraoperative bleeding, and that could be more substantial and concerning or injury to surrounding structures. And so far, I think actually now that I'm thinking about it, I feel like there may have been a visit with concern for bleeding, but no OR visits from my patient population so far. But again, I don't have the data in front of me, so don't quote me. You know, it's less postoperative pain is the other thing, you know, patients bounce back a lot, have a lot of returns to emerge for dehydration and or admission for pain reasons. And that you see just much less with the coblator. Again, using my feeling about it rather than having the data right in front of me for my personal data, but that's what the data shows in literature as well. 

Kyrollos: And you already kind of mentioned how with an intracapsular approach, because you're not removing the capsule, there's always a little bit of risk of tonsillar regrowth. And that's something you monitor for. Can you tell us a little bit more about how you monitor for tonsillar regrowth? 

Dr. Graham: Well, that's interesting, because usually after tonsillectomy, we don't see our patients back unless there's a concern. So the reason for that is our wait lists are long, and so this allows us to see more new patients. And again, people can call us if they want to be or if they need to be seen. Tonsillar regrowth is going to happen. My series is still quite short, actually, right? Because I've just started in April and I've left another institution. So we'll see, you know, this will be something that we see over the next five, ten years. The other thing about a learning curve, which I think is appropriate, is that earlier in practice, people are more likely to leave a bit more tonsil behind, and I'm okay with that, because I am offering them the benefits of an intracapsular child to select me. So if I go through the capsule, then I put them at the same risks of an extracapsular tonsillectomy, which they didn't sign up for, right? So I prefer my trainees and even myself, you know, err on the side of caution, right? Leave a little bit behind so that they're getting the surgery they signed up for rather than getting the complications of the procedure they didn't sign up for, right? 

Kyrollos: Right. Okay, and in terms of kind of doubling back to that question, I asked earlier about contraindications and things like that. Are there any age-related factors? Obviously, you deal entirely with the pediatric population. So are there any age related factors or maybe anatomical considerations in younger kids that influence your choice of surgical technique? 

Dr. Graham: So I would feel much more comfortable doing an intracapsular tonsillectomy on a really little baby, or you know, if I needed to, it's uncommon that I'm doing a tonsillectomy under the age of two. kids who are three and under we admit. That's sort of like a, you know, policy - umbrella kind of policy. But, you know, a post-tonsillectomy bleed in a younger child is much more devastating because of cooperation to deal with it in the emerge area and then just blood volume, right? It's a more worrisome thing. So I like an intracapsular tonsillectomy better in a younger child. That said, I had some conversations with colleagues at our national meeting and some feel if a child is under the age of six, they'd really rather do an extracapsular, because the more time you have to grow, the more likely you are to regrow. So I think in an adult, if you had an intracapsular, you'd probably be less likely to regrow than if you were a small child. Same as adenoids. If you do an adenoidectomy and someone under the age of three, by any method, you're more likely to have regrowth and possibly need to revision adenoidectomy. 

Kyrollos: Yeah. Okay. And once again, just kind of touching on that difference between ICT and extracapsular approach, in terms of like the postoperative analgesia regimen, do you recommend a different one for ICT? 

Dr. Graham: That's a great question. So I try and emphasize non-opiate analgesia no matter what. But I think that they're more likely to need opiates if they're having an extracapsular. So my counselling is very similar for the two tonsillectomies, except for - I'll tell you what I say for an extracapsular. For an extracapsular, I usually recommend Tylenol (and) Advil, alternating around the clock for the first 48 hours, and then they can, you know, dial back a little bit, use it more PRN. But I do recommend, you know, using those two agents as much as possible and reserving opiates for more severe pain. I often find they need opiates for more severe pain in the first, 48 (hours) or days 5 to 7 after surgery, which is often a peak in pain in extracapsular tonsillectomies. I find the recovery is more like a week for the intracapsular tonsillectomies, and I also think that they use the opiates less. I still want them to have them available. I still talk about piggybacking Tylenol and Advil. Usually I say more like, you know, see how that goes for the first 24 hours around the clock and see what you child is needing then? Because if they're pushing - you've got this child who's not having any pain and they're pushing the Tylenol and the Advil, that might be more trouble than it's worth, but I still want them to focus on those non-opiate analgesic agents to start. I send them home with morphine, but I say, don't use it if you don't need it, because these are the side effects. And again, I send a low, like 0.1 per kilo, very low dose and just a few doses. Usually I'll send home, you know, 10 or less kind of thing. And so far that's worked for me. Again, it's a bit tricky with our data because we don't bring them back to follow up. From a research perspective, it might make sense for us to start following those at least with phone call for a bit. But the data that we have from Western looks really positive. 

Kyrollos: And at Western, would you guys typically follow up? 

Dr. Graham: I usually call them at four or six weeks, yeah, to see how they did. But again, it was more of a, you know, touch base kind of thing. 

Kyrollos: Yeah. And so you're saying when you would call them they're - usually in terms of pain, it's usually better. 

Dr. Graham: Yeah and I mean, again, they weren't usually coming back to hospital. That's the other thing. Like, sometimes we have pain crises and things like that with the extracapsular, and that's much less common, I find with the intracapsular. 

Kyrollos: And I guess in otolaryngology as a whole, there's been - and medicine as a whole. There's obviously a lot of new technology coming out. Do you see coblation ICTs, or ICTs in general, becoming the new standard of care for pediatric populations. 

Dr. Graham: That's a good question. And some places it is. I think, my impression is in Europe, it's much more common to do intracapsular tonsillectomies. I don't think that extracapsular tonsillectomies are necessarily a bad thing. I think there's a role for them, and particularly kids who we’re worried that they're going to have persistent symptoms after tonsillectomy for sleep or whatever. And for the recurrent strep tonsillitis, for some families, and I understand having that debate, you know, the reason they're having the surgery is because they're missing so much school for an infected tonsil. If there's a chance that there could be a little bit of tonsil that still gets infected, you know, they might not be on board for that. I think that there's a role for all types of tonsillectomy and nothing's going to go away, but we need to have a bunch of things in our tool belt to modify the risks so they're acceptable for patients. And, you know, use shared decision making to do what's in line with their values and goals. 

Kyrollos: So if I'm getting you correctly, even though it's definitely becoming a more prominent technique, and the data shows that it might also be correlated with better outcomes. It's still important to know the different approaches. 

Dr. Graham: Yes, for sure. And I think it, you know, from a post-operative recovery standpoint, yes, for sure. Those outcomes are better. For some people, regrowth is going to be a big problem, right? Having another surgery, if you're a fragile child, another GA, although again, if you're a fragile child, you want a bit more, but easy recovery. So it's a bit of a debate, right? And I'm not sure if we look at the data, whether long-term outcomes suggest that ICT is definitely superior or not. We’d have to examine that data. I think that there will always be a rule for an extracapsular tonsillectomy, and it's important that we know how to do those as surgeons. And again, there's lots of different ways to do that. I'm not sure that it will ever completely replace extracapsular tonsillectomy, but I think it's a really useful adjunct, and I would say far and away, it is going to be the biggest portion of my practice. 

Kyrollos: Yeah. Okay, and sorry, just another follow-up question.. I asked you already about monitoring for tonsillar regrowth in ICTs. In cases where regrowth does happen, do you go again with the coblator or with an intracapsular approach? Or do you then switch to extracapsular? That's a great question. And I haven't a ton of those yet. Again, my series is short. I would offer to take it out with a coblator again if it was sleep disordered breathing. If they wanted it back because they were having recurrent strep infections, then I'd probably try and take the tonsil out all the way. I would expect it'd be harder because we're going to have a scarred capsule, right? We try and leave it intact, but we're close to it. So that plane will be a little trickier to find. I think doing an intracapsular again gives you the same kind of risks, especially if they're an older child. I think it's, you know, a positive idea. But again, this is a very shared decision-making moment. If families are like, what is happening? I'm having another surgery. Just get these out of here, then that's a, you know, that's completely reasonable as well.

Kyrollos: So it's much more engaging with the patient than the family. 

Dr. Graham: Yeah, for sure. Yeah, exactly. I think there's not a wrong answer here, but shaving them out again is nice, especially if it's for sleep, right? Yeah, it's lower risk. 

Kyrollos: Yeah. And, what advice would you give as a staff to med students and residents who want to get a bit more of a hands-on experience with tonsillectomies in general and particularly with a coblation intracapsular tonsillectomy?

Dr. Graham: It's pretty tricky to get hands-on experiences that you know, it's a bit of a one person surgery, right? I would say show interest, you know, be close when they're happening, watch, learn the techniques. For coblator, there's lots of video, actually, there's - I have no connection with Smith and Nephew - but that's the company that does coblator. They have like Smith and Nephew Academy or something like that. You can find videos where you just register and you can find videos guiding you through intracapsular tonsillectomies, which I find helpful and I sometimes look at them still, just to get extra tips from the people who do them the most. And then a coblator, actually, you can sometimes they'll let you use it on a strawberry, which is a fun way to practice. So if there's a rep in the OR, you can ask if they have any tools that you could, you know, sample tools that are open to see if you could kind of play with it to see what it feels like, you know, being interested, being close, going to the OR as much as you can, are really the keys. 

Kyrollos: Definitely. Thank you for that. And I guess just going to a more general question: what do you think the future of otolaryngology looks like, especially in terms of minimally invasive surgeries? Like, even we've talked about ICT so far, would you consider that a more minimally invasive surgery in comparison to an extracapsular approach? 

Dr. Graham: For sure, I would, yeah, it's definitely more minimally invasive, you know, and the risk is recurrence, right? Compared to risk of more serious post surgical complications. I do think that that's the future. And, you know, looking at the way that we manage pain for kids, I think is really important, especially little kids, the experience of pain. We are in early stages of looking at if the pain and bleeding associated with tonsillectomy has any longer term outcomes or like psychological outcomes, because I do see families sometimes - you know, say a parent has had a tonsillectomy bleed and they still remember it. You know, or I see a child in follow-up when the child has had a post-tonsillectomy bleed, and the parents are really affected. And I think we need to be looking at the overall impact of the things that we do, even psychologically on our patients. 

Kyrollos: Definitely. And in terms of procedures even outside of tonsillectomy, in terms of minimally invasive surgery in general, where do you think that's going? 

Dr. Graham: That's an interesting question. There's not a ton like that, I guess, in peds, except there's a move in some places for in office tubes, like even in little kids. I'm not a believer yet, but I haven't seen them in real life and it seems like it'd be tricky to get a child through that. Maybe one you could do, but I don't know if you'd be able to get the second done. I think that people are always looking at ways to improve delivery of care, especially in a resource challenged environment, like in Canada, right? We have issues with access to care and lengths of waitlist and so on. So it's good to look at ways that we can move patients through more quickly in a safe way to deliver care faster. But yeah, it's just, there's lots, you know, lots more to learn about how we can do that. 

Kyrollos: It's definitely great to see that these types of considerations are being made. And, you know, thank you so much for doing this today. It was definitely a great high-level overview of tonsillectomies, and I think people are really going to benefit from this. Was there anything else you wanted to add before closing this off? 

Dr. Graham: No, it was great to chat with you. Again, you know, this is my feeling and my opinions based on the data and my personal experience. You know, I think it's going to be interesting to watch the way that practice shifts with respect to tonsillectomy over time. It really has changed a lot even in the last, you know, 15 years, which I found kind of surprising. And, you know, I continue to look at the data and if, you know, the more I learn, the more I'll change what I do to sort of optimize patient care. 

Kyrollos: So it's fair to say that even like we always hear in medical school that you never stop learning, even as a staff and all the way through. I guess that's that's a very fair thing to say then. 

Dr. Graham: 100%. Yeah, I learned to do these coblation intracapsular tonsillectomies five years into practice. And I wouldn't have expected that I would make this shift because like I said, I was like, why would I do an intercounter tonsillectomy? They're so annoying. But, you know, when you look at the data, they're better and actually the more you do, the more comfortable you feel and looking at those improved patient outcomes and decreased visits for tonsil bleeds is really worth it. So yeah, I'm happy with that change. For sure. 

Kyrollos: Well, thank you so much for taking the time out of your day to sit down with us today. I think it's really beneficial. 

Dr. Graham: Great, thanks. It was my pleasure.

Kyrollos: Thank you for listening to this episode of The Oto Approach. Stay tuned for more conversations on key topics in otolaryngology coming your way soon.