The Laryngoscope

Lippincott Williams & Wilkins, Inc.

© 2006 The American Laryngological,
Rhinological and Otological Society, Inc.

Letters to the Editor

Canal Wall Reconstruction Authors’ Response

Tympanomastoidectomy With
Mastoid Obliteration Dear Editor:
Dear Editor: We thank Professor Deitmer for his comments and
pointing out the important work of Professor Harald Feld-
Reading the journal for more than 20 years now, I mann. We were aware of his contribution to the canal
realize more and more that this journal is open to inter- removal technique and the novel saw that he developed. It
esting articles from all over the world and provides a was an oversight on our part not to mention the publica-
comprehensive overview about scientific activities in the tions that were listed in Professor Deitmer’s letter. Our
whole “ENT world.” intent on publishing our results with the canal wall recon-
I want to comment on the publication by Prof. Gantz, struction technique was to illustrate the important contri-
whom I had the honor and opportunity to visit some years bution that Ulf Mercke from Lund, Sweden, added to the
ago in his busy department. Concerning the canal wall canal wall reconstruction strategy. As Professor Deitmer
reconstruction (CWR) technique the ENT Department of mentioned, the problem with replacing the canal wall
the University of Muenster in Germany has performed without obstructing the attic is reretraction of the tym-
since the 1970s. My teacher, Prof. Dr. Med Harald Feld- panic membrane. Dr Mercke introduced the mastoid oblit-
mann, described the technique in the 1970s in the German eration technique. This appears to control recurrent re-
and English language literature and we performed several traction pocket formation. Most ears with chronic otitis
hundred cases. Together with the Karl Storz Company, he media and cholesteatoma continue to have eustachian
designed a microsurgical saw in which one could adjust tube dysfunction. If the ear drum does retract, it is limited
the depth of the oscillations of the blade to work in a more to the tympanum without pocket formation. Professor Deit-
atraumatic way at the inferior cut (facial nerve) and the mer also confirms that residual disease is rare in the
superior cut (dura). Our experience with this technique mastoid because of the excellent view provided by removal
has not been systematically investigated, but in our se- of the canal wall for access to the entire middle ear and
ries, we had several cases with retraction pockets as a mastoid.
result of poor function of the eustachian tube. Some cases
developed a cholesteatoma with this mechanism. On the BRUCE J. GANTZ, MD
other hand, residual cholesteatomas were very rare, be- MARLAN HANSEN, MD
cause the technique gives an excellent overview compared ERIC WILKINSON, MD
with a canal wall up technique. Perhaps the modification Dept of Otolaryngology–Head and Neck Surgery
to perform an obliteration of the mastoid cavity as Prof. University of Iowa, Iowa City, Iowa
Gantz describes is a decisive detail. We did not obliterate
but hoped to have reventilation of the cavity. I discussed
this issue with Prof. Feldmann, who is going to celebrate
Ligasure versus Cold Knife Tonsillectomy
his 80th birthday in February 2006 and is still active in
scientific publications.
Dear Editor:
THOMAS DEITMER, MD, PHD I believe Lachanas et al.1 to have included significant
ENT Department bias on a number of counts into their comparison of tech-
Klinikum Dortmund niques for tonsillectomy. The study reports significantly
Dortmund, Germany reduced operative time, bleeding, and pain in tonsillec-
tomy performed using the Ligasure instrument compared
with the cold knife technique. Detailed analysis of the
BIBLIOGRAPHY available information allows alternative interpretation of
1. Feldmann H. Osteoplastic approach in chronic otitis media by the data; therefore, I believe the methodology and results
means of a microsurgical reciprocating saw. Clin Otolar- collected do not justify the conclusions drawn.
yngol 1978;3:515–520. There is no reference in the article as to the method
2. Feldmann H. Osteoplasty cholesteatoma and mastoid surgery.
Proceedings of the 2nd International Conference; Tel Aviv, used for randomization of patients to either group or sur-
Israel; March 22–27, 1981. Amsterdam: Kugler Publica- geon. This is important to disclose, because bias may be
tions; 1982:479 –482. introduced if the two surgeons used only one of the two

Laryngoscope 116: July 2006 Letters to the Editor

1299
techniques each compared with using both techniques as- manuscript was shortened, and a description of the cold
signed randomly. knife technique was not included in the final text,
Do both surgeons involved perform their cold knife whereas Ligasure tonsillectomy, which is a new tech-
dissections in exactly the same manner? The method for nique, was described in great detail. In our department,
the Ligasure technique is described in great detail in cold knife tonsillectomy is usually performed by incision
the report, but the traditional cold knife method used of the anterior pillar with a 15-bisturi blade. The peri-
for comparison is not detailed. For example, did they tonsillar plane is located and the tonsil is then dissected
use ties or snares for the inferior pole, and what method toward the inferior pole. The inferior pole is clamped
of hemostasis was used? This can affect the operative with a Negus clamp, the tonsil specimen is removed,
time.2 It was indeed shown that cold knife tonsillectomy and a tie is placed to secure hemostasis. The fossa is
takes significantly longer than the method using the then packed with cottonoid pledgets and the other tonsil
Ligasure device, but there is no explanation as to why is similarly removed. The cottonoid pledgets are re-
this might be. A comment in the discussion may have moved in the order in which they were placed and, when
clarified the reasons, especially because one case of cold necessary, ties or sutures are used to secure hemostasis.
knife tonsillectomy had a blood loss of more than 400 This technique was used by the two senior surgeons
mL. Why was this? Perhaps this case alone may have (GV, EP) who participated in the comparative study of
skewed the results. “Ligasure versus Cold Knife Tonsillectomy,” in all pa-
It can be seen that the authors are very practiced in tients of the cold knife tonsillectomy group, whereas
the use of the Ligasure instrument.3–5 Indeed, it could be both surgeons (GV, EP) used both techniques (Ligasure
inferred that they routinely use this method for tonsillec- tonsillectomy and cold knife tonsillectomy) assigned
tomy in preference to the cold knife method. If this is so, randomly.
could it not also significantly bias the comparison of the With regard to the patient with the 432-mL blood
two techniques? A surgeon using a well-practiced and loss,1 we believe that a great intraoperative hemorrhage is
regularly performed technique is less likely to encounter experienced by all active otolaryngologists at some point
complications than when performing the same procedure
in his or her career. We do not believe that this single
using a senescent technique at which one is out of
patient could have skewed our results, because in the
practice.
Ligasure tonsillectomy group, there was no measurable
bleeding during surgery in any of the cases,1 whereas the
OWEN JUDD, MRCS, DCH
number of patients enrolled our study (Ligasure tonsillec-
Department of Otolaryngology, Head and Neck Surgery
tomy and cold knife tonsillectomy groups consisted of 108
Derriford Hospital
and 92 individuals, respectively1) was statistically suffi-
Plymouth, U.K.
cient enough to justify our conclusions.
In our department, we have widely used the Ligasure
BIBLIOGRAPHY Vessel Sealing System in otolaryngology– head and neck
1. Lachanas VA, Prokopakis EP, Bourolias CA, et al. Ligasure surgery procedures1–5 since 2002, whereas in tonsillec-
versus cold knife tonsillectomy. Laryngoscope 2005;115:
1591–1594. tomy procedures, it was first used in 2003.2 Although our
2. Leach J, Manning S, Schaefer S. Comparison of two methods of senior surgeons (GV, EP) were familiar with the device in
tonsillectomy. Laryngoscope 1993;103:619 –622. head and neck surgery, Ligasure tonsillectomy was a new
3. Prokopakis EP, Lachanas VA, Benakis AA, et al. Tonsillec- technique, and there is always a learning curve in all new
tomy using the Ligasure Vessel Sealing System. A prelim-
inary report. Int J Pediatr Otorhinolaryngol 2005;69:
techniques, whereas cold knife tonsillectomy, as described
1183–1186. previously, has been the “gold standard” technique in our
4. Lachanas VA, Prokopakis EP, Mpenakis AA, et al. The use of department for the last 15 years, since the first opera-
Ligasure Vessel Sealing System in thyroid surgery. Oto- tional year of University Hospital of Crete in 1990. Unde-
laryngol Head Neck Surg 2005;132:487–489.
5. Prokopakis EP, Lachanas VA, Karatzanis AD, et al. How we
niably, our senior surgeons were at least as practiced and
do it: application of Ligasure Vessel Sealing System in familiar with cold knife tonsillectomy as with the new
patients undergoing total laryngectomy and radical neck Ligasure tonsillectomy technique! So, we do not believe
dissection. Clin Otolaryngol 2005;30 that this factor could bias the comparison of the two
techniques.
In conclusion, we believe that Ligasure tonsillectomy
Comparative Study of Ligasure Tonsillectomy is an effective alternative tonsillectomy technique, which
versus Cold Knife Tonsillectomy provides sufficient hemostasis, lower postoperative pain,
and reduced operative time. We believe that further stud-
Dear Editor: ies from other colleagues will also confirm our results.

This is a response to Dr. Owen Judd’s letter regard- VASSILIOS A. LACHANAS, MD

ing our article, entitled “Ligasure versus Cold Knife EMMANUEL P. PROKOPAKIS, MD
Tonsillectomy,” published in the September 2005 issue.1 EMMANUEL S. HELIDONIS, MD, FACS
The Laryngoscope requires a page limit to almost all GEORGE A. VELEGRAKIS, MD
submissions to be considered for publication. Thus, ac- Department of Otolaryngology, University of Crete
cording to the reviewers’ suggestions, the length of our School of Medicine, Heraklion, Crete, Greece

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