ORIGINAL RESEARCH–GENERAL OTOLARYNGOLOGY Evaluating postoperative pain in monopolar cautery versus harmonic scalpel tonsillectomy Sharon L. Cushing, MD, MSc, Oakley Smith, MD, FRCS(C), Albino Chiodo, MD, FRCS(C), William Elmasri, MD, FRCS(C), and Pam Munro-Peck, RPN, Toronto, Ontario, Canada Sponsorships or competing interests that may be relevant to con- tent are disclosed at the end of this article. ABSTRACT OBJECTIVES: To compare postoperative pain between mono- polar cautery tonsillectomy and harmonic scalpel tonsillectomy (HST). STUDY DESIGN: Randomized controlled trial using paired organs. SETTING: Community hospital with academic affiliation. SUBJECTS: One hundred and fourteen consecutive patients six years of age or older undergoing tonsillectomy for indications of hypertrophy or recurrent infection. METHODS: For each subject, monopolar cautery tonsillectomy was performed by four senior surgeons on one side and HST was performed on the other side. Allocation of technique to side was randomized and revealed to the surgeon at the start of the opera- tion. Validated visual analog pain scales were used to quantify pain at rest and with swallowing for each side and were completed daily for 14 days. All subjects were prescribed weight-equivalent doses of analgesics. Secondary outcome measures included postopera- tive complications (hemorrhage and readmission). RESULTS: Pairwise comparisons of pain scores revealed no significant difference between monopolar cautery tonsillectomy and HST (P  0.05). CONCLUSIONS: Subjects undergoing monopolar cautery ton- sillectomy do not experience increased postoperative pain in com- parison to HST. © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. T onsillectomy is one of the most commonly performed surgical procedures in otolaryngology– head and neck surgery, and a growing number of surgical technologies have been applied and evaluated in this setting. The most relevant outcomes in these evaluations include intraopera- tive blood loss, postoperative hemorrhage, and pain. Con- tinued evaluation of new techniques and technologies for tonsillectomy is fueled by an accepted postprocedure pri- mary and secondary hemorrhage rate from 0.8 to seven percent, 1,2 with some instances of hemorrhage being of considerable morbidity, including return to the operating room, blood transfusion, and death. In addition, tonsillec- tomy leads to significant postoperative pain for a period of seven to 14 days, with the severity of pain often graded as moderately severe, requiring narcotic analgesia and, at times, readmission to hospital for hydration and intravenous analgesia. Herein lies the impetus to develop and evaluate additional techniques for tonsillectomy that minimize both pain and postoperative hemorrhage. Achieving an optimal balance between intraoperative blood loss and early and delayed hemorrhage while minimizing postoperative pain has been the motivation for ongoing evaluation of varied techniques for tonsillectomy, and to date no single tech- nique has been shown to optimize all considerations. In the current study, we set out to specifically compare postoperative pain following monopolar cautery tonsillec- tomy (MCT), a readily accepted and widely used technique for tonsillectomy, and harmonic scalpel tonsillectomy (HST) (Ethicon Endo-Surgery, Cincinnati, OH). The har- monic scalpel (HS) was introduced in 1993 and has since gained accepted use in the setting of laparoscopic surgery. This technology was first employed in Canada for the re- moval of tonsils in March 1997 by Dr Ronald S. Fenton and was outlined by this same author in 2000. 3 The HS employs ultrasonic energy through high-frequency vibration (55.5 kHz) over a small amplitude (50 to 80 m). When applied over a large surface area, tissue coagulation occurs, and when coupled with a sharp edge, tissue cutting is achieved. Coagulation is thought to occur through coaptation, where ultrasonic energy disrupts hydrogen bonds and denatures protein, producing a coagulum that coapts small vessels. 4 In contrast, cutting occurs through the application of ultrasonic energy over the small, relatively sharp surface of the instru- ment tip through the mechanism of cavitational fragmenta- tion, which leads to disruption of low-density tissues. 4 Given the nature of the applied energy, relatively low tem- peratures (50°C to 100°C) are generated by the HS, and thermal injury to adjacent tissue is thought to be minimal. In comparison, MCT cuts tissues and seals blood vessels by Received April 7, 2009; revised July 25, 2009; accepted August 20, 2009. Otolaryngology–Head and Neck Surgery (2009) 141, 710-715 0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2009.08.023