Description:
Traditionally, tonsillectomy has been performed by means of "cold" dissection. The tonsil and its capsule are separated from the surrounding tissues using metal instruments (i.e., scissors, snare or knife). The upper pole of the tonsil is mobilized, then dissection continues to the base of the tongue.

A laser-assisted tonsillectomy may describe any of the following procedures: 1) the use of a laser as a surgical tool in an otherwise standard tonsillectomy procedure; 2) the use of the laser to sequentially vaporize the tonsils in a series of outpatient visits; and 3) the use of the laser to vaporize the surface of the tonsils, i.e., a cryptolysis or a subtotal tonsillectomy. 

Either a hand-held carbon dioxide laser (Acupulse^® 30 and 40, Lumenis, Inc., Santa Clara, CA), a potassium-titanyl-phosphate laser (KTP/532), diode laser (Quanta System Diode Medical Laser System^®, Quanta System SpA, Olona VA, Italy) or an ND:YAG long pulse laser (NaturaLase LP^® Laser, Focus Medical, Bethel, CT) may be used.

Policy:
A laser-assisted total tonsillectomy performed in either a single sitting or by serial surgery is considered NOT MEDICALLY NECESSARY.

A subtotal or partial tonsillectomy (cryptolysis) is INVESTIGATIONAL.

Benefit Application:
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and, thus, these devices may be assessed only on the basis of their medical necessity.

A laser-assisted tonsillectomy may be coded using standard codes for tonsillectomy using a -52 modifier, indicating reduced service. Laser-assisted tonsillectomy performed as a serial procedure may be identified by submission of more than one claim for a tonsillectomy.

Rationale:
2006 Update
A technology review from the Canadian Agency for Drugs and Technologies in Health found no evidence to support an improvement in health outcomes with laser-assisted tonsillectomy or tonsillotomy.³

2007 – 2008 Update
One study was a randomized within-subject double-blind comparison of tonsillectomy performed with laser, blunt dissection, electrocautery or radiofrequency coblation.⁴ For each of the 60 adult patients, tonsillectomy was performed with coblation on one randomly chosen side; for the other tonsil one of the other three "standard" techniques was used (20 patients per comparison group). Pain ratings were higher for laser and electrocautery than for blunt dissection and coblation. Both operative time and blood loss were higher for laser (20 minutes and 20 mL, respectively) than coblation (10 minutes and 2.5 mL). Laser and electrocautery resulted in more histopathological thermal tissue injury than coblation. Healing, determined by a blinded evaluator, was slower for electrocautery, but similar for blunt dissection, laser and coblation. No evidence was found to suggest that use of a laser improves health outcomes in comparison with other methods.

Guidance from the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) considers safety and efficacy data to be adequate to support the use of this technique.⁵ Efficacy data indicate slower wound healing and increased pain between 24 hours and two weeks after surgery compared with cold-steel dissection. It was also noted that although intraoperative blood loss may be less, the risk of postoperative hemorrhage may be greater. There is also a risk of damage to the patient’s face and upper airway.

Partial Tonsillectomy
One study prospectively compared partial tonsillectomy (tonsillotomy) by laser with blunt dissection tonsillectomy in 113 children.⁶ The authors noted that a randomized study could not be conducted since (in Germany) tonsillotomy is strictly contraindicated in patients with recurrent throat infections. Therefore, children who had obstructive problems (snoring, sleep apnea, mouth breathing and eating problems; n = 49) and no history of infection were treated with tonsillotomy, while those who had recurrent tonsillitis (n = 64) underwent tonsillectomy with blunt dissection. For the tonsillotomy group, no postoperative hemorrhage occurred; the mean time to discharge was three days (range: 1 – 6). In the tonsillectomy group, three (5 percent) children had postoperative hemorrhage; the time to discharge was 6.9 days (range: 5 – 12). Follow-up contact was achieved for parents of 40 children (82 percent) in the tonsillotomy group. Two of the 40 (5 percent) had regrowth of tonsillar tissue and required a subsequent tonsillectomy; none of the children with tonsillotomy were reported to have had recurrent tonsillitis (average: 16 months; range: 6 – 24 months). Follow-up contact was achieved for parents of 57 children (89 percent) in the tonsillectomy group, who only reported on postoperative analgesic use. Additional studies with longer follow-up are needed to evaluate rates of postoperative hemorrhage, regrowth and recurrent tonsillitis with partial tonsillectomy. Therefore, the policy statements remain unchanged.

2009 Update
A prospective, randomized, clinical study⁷ (n = 80, males = 35), conducted in Egypt, sought to compare the advantages and disadvantages of potassium titanyl phosphate (KTP) laser with those of bipolar radiofrequency techniques in pediatric patients aged between 10 and 15 years with tonsillectomy planned for chronic tonsillitis. Patients were prospectively randomized into two equal groups: KTP laser tonsillectomy (n = 40) and bipolar radiofrequency tonsillectomy (n = 40). The outcome measures included; operative time, intraoperative blood loss, postoperative pain and rate of postoperative complications. Follow-up visits were scheduled during the first, second and fourth postoperative weeks. Patients were asked to record their pain and discomfort on a standardized visual analogue scale (VAS).

Results:

• Operative time: Operative time ranged from 6 to 14 minutes in the radiofrequency group and from 9 to 15 minutes in the KTP laser group; tendency was for a shorter operative time in the radiofrequency group, but this did not reach statistical significance.
• Intraoperative blood loss (ml): blood loss ranged from 25 to 35 ml in the radiofrequency group and 21 to 30 ml in the KTP laser group; the mean difference of 9 ml was statistically significant.
• VAS: First postoperative week, pain and discomfort range of scores was from 7.5 to 9.5 for the radiofrequency group and from 6 to 9 in the KTP laser group; there was no statistically significant difference between groups; the second postoperative week pain and discomfort range of scores had increased for the KTP laser group (range 7.5 to 9.5), as compared with a decrease in the radiofrequency group (range 5 to 7); this difference was not statistically significant; in the fourth postoperative week, both groups showed an equal improvement in pain score with a reduction in pain to normal levels.
• Postoperative complications: The authors noted there was no statistically significant difference between groups regarding postoperative complications. However, the article did not provide complication rate data for the treatment groups or the overall rate of complications.

The authors concluded that both KTP and the bipolar radiofrequency techniques were safe and easy to use for tonsillectomy. Conclusions need to be tempered by the small size of the study groups, lack of inclusion of cold steel dissection technique (considered the gold standard technique) and need for long-term follow-up. In conclusion, future clinical trials comparing surgical techniques will need to ensure that the procedures are standardized, and outcome measures validated for both symptoms and surgical complications.

Summary:
No evidence was identified that would alter the conclusions reached above. The policy statements remain unchanged; the total laser-assisted tonsillectomy procedure is considered NOT MEDICALLY NECESSARY and subtotal or partial tonsillectomy (cryptolysis) is INVESTIGATIONAL, given the insufficient evidence available to evaluate the net health outcomes in comparison with alternative surgical procedures.

References:

1. Auf I, Osborne JE, Sparkes C et al. Is the KTP laser effective in tonsillectomy? Clin Otolaryngol 1997; 22(2):145-6.
2. Nelson LM. Radiofrequency treatment for obstructive tonsillary hypertrophy. Arch Otolaryngol Head Neck Surg 2000; 126(6):736-40.
3. Scott A. Hot techniques for tonsillectomy. Issues Emerg Health Technol 2006; (93):1-6. 
4. Magdy EA, Elwany S, El-Daly AS et al. Coblation tonsillectomy: a prospective, double-blind, randomised, clinical and histopathological comparison with dissection-ligation, monopolar electrocautery and laser tonsillectomies. J Laryngol Otol 2007
5. National Institute for Health and Clinical Science. Tonsillectomy using laser. 
6. Reichel O, Mayr D, Winterhoff J et al. Tonsillotomy or tonsillectomy?--a prospective study comparing histological and immunological findings in recurrent tonsillitis and tonsillar hyperplasia. Eur Arch Otorhinolaryngol 2007; 264(3):277-84.
7. Hegazy HM, Albirmawy OA, Kaka AH et al. Pilot comparison between potassium titanyl phosphate laser and bipolar radiofrequency in paediatric tonsillectomy. J Laryngol Otol 2008; 122(4):369-73.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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