The Laryngoscope

V
C 2012 The American Laryngological,
Rhinological and Otological Society, Inc.

How I Do It

Early Experience of Radio Frequency Coblation in the Management of

Intranasal and Sinus Tumors

Mohammed Iqbal Syed, MD, MRCS; Joanna Mennie, MBBS; Alun T. Williams, MD, FRCS

The purpose of this study was to evaluate the safety and efficacy of the use of radiofrequency coblation for en-
doscopic resection of intranasal and sinus tumors. A review was conducted of 15 adult patients with intranasal and
or sinus tumors endoscopically treated with radio frequency coblation between November 2008 and November 2010
at St. John’s Hospital at Livingston, a tertiary referral center that covers otolaryngology services for the southeast
of Scotland. Fifteen patients with intranasal and sinus tumors were treated with transnasal endoscopic resection
using radiofrequency coblation. The tumors included inverted papilloma (seven), paraganglioma (one), glomangioper-
icytoma (one), capillary hemangioma (one), hemangiopericytoma (one), juvenile angiofibroma (one), juvenile ossify-
ing fibroma (one), oncocytic adenoma (one), and transitional cell carcinoma (one). We found that radiofrequency
coblation is a useful and safe tool associated with minimal blood loss (<200 mL to 600 mL) in the resection of these
tumors, and the average operating time was 1.67 hours. Radio frequency is a rapidly evolving technique and in the
future will have an increasing role to play in the endoscopic resection of intranasal and sinus tumors.
Key Words: Coblation, sinonasal tumors.
Laryngoscope, 122:436–439, 2012

INTRODUCTION ment and a sucker) have been described, although

Sino nasal tumors represent a therapeutic challenge
because of difficulties with access. Traditionally, methods
for resection involved open approach surgery such as
lateral rhinotomy, Denker’s procedure, and midfacial
degloving. It is widely accepted that even with these
techniques, resection is rarely if ever en bloc and onco-
logical in nature, and the extensive dissection required
can be associated with significant morbidity. With the
evolution of endoscopic sinus surgery, techniques have
been developed for endoscopic excision of nasal and
sinus tumors. The instrumentation used in these techni-
ques has included manual cold steel dissection,
microdebriders, and laser (light amplification by stimu-
lated emission of radiation). The difficulties with
endoscopic tumor excision include adequate access, the
need to frequently debulk and remove tumor piecemeal,
and bleeding. Two-surgeon approaches with one surgeon
operating the endoscope and the other able to hold an
instrument in each hand (usually an operating instru-
From the Department of Otolaryngology, The Royal Infirmary,
Edinburgh, United Kingdom.
Editor’s Note: This Manuscript was accepted for publication July
25, 2011.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Mohammed Iqbal Syed, MD, Specialist
Registrar in Otolaryngology, The Royal Infirmary, Edinburgh E16 4SA,
UK. E-mail: iqbalms@hotmail.com
DOI: 10.1002/lary.22420
limited space can make these techniques challenging.
The EVac 70 (ArthroCare, Sunnyvale, CA) coblation
plasma wand is marketed for use in tonsillectomy and
adenoidectomy, and the senior author’s experience with
the instrument in tonsillectomy suggested and led to the
use of this instrument in endoscopic nasal and sinus
tumor resection. The instrument has suction, saline irri-
gation, and bipolar coagulation and cutting capabilities
all at the tip of a single instrument, allowing tissue
resection and hemostasis to be achieved with a clear
field of view.
We report our early experience of 15 cases of nasal
and sinus tumors in which most or all of the endoscopic
dissection was performed using the EVac 70 wand. The
range of cases and operative and postoperative events
are discussed, along with the apparent advantages, limi-
tations, and possible future development of coblation
technology in this application.
MATERIALS AND METHODS
After obtaining appropriate local ethical committee ap-
proval, the case notes of 15 patients with intranasal and or
sinus tumors who underwent endoscopic resection using radio-
frequency coblation by the senior author at St. John’s Hospital
at Livingston, a tertiary referral center that covers otolaryngol-
ogy services for the southeast of Scotland, from November 2008
to November 2010 were retrieved. The data collected included
patient demographics, histopathological diagnosis, operative
technique, operating time (OT), estimated blood loss (EBL),
complications, and information on postoperative follow-up.

Laryngoscope 122: February 2012 Syed et al.: Management of Intranasal and Sinus Tumors
436
 TABLE I.
Radiofrequency Coblation-Assisted Resection of Intranasal and Sinus Tumors.
Patient No. Age, yr Sex Diagnosis Procedure EBL, mL OT, hr

1 53 F Inverted papilloma Endoscopic resection <200 1.35

2 45 M Inverted papilloma Endoscopic resection <200 1.23
3 75 M Inverted papilloma Endoscopic resection 400 1.05
4 71 M Inverted papilloma Endoscopic resection þ medial maxillectomy 300 1.1
5 60 F Inverted papilloma Endoscopic resection þ medial maxillectomy 300 1.3
6 34 M Inverted papilloma Endoscopic resection þ medial maxillectomy <200 1.2
7 37 M Inverted papilloma Endoscopic resection þ medial maxillectomy <200 1.5
8 20 M Paraganglioma Endoscopic craniofacial resection <200 1.2
9 54 M Glomangiopericytoma Endoscopic craniofacial resection 400 2.12
þ CSF leak repair
10 74 M Capillary hemangioma Endoscopic resection <200 1.3
11 52 M Hemangiopericytoma Endoscopic craniofacial resection 400 2.3
12 17 M Juvenile angiofibroma Endoscopic resection 600 4.3
13 24 M Juvenile ossifying fibroma Endoscopic resection 400 2.4
14 67 M Oncocytic adenoma Endoscopic resection <200 1
15 70 F Transitional cell carcinoma Endoscopic resection 400 1.38
Recurrent transitional cell carcinoma Endoscopic craniofacial resection 500 2.3
F ¼ female; EBL¼ estimated blood loss; OT¼ operating time; M ¼ male; CSF ¼ cerebrospinal fluid.

All patients underwent surgery under general anesthesia. Surgical Technique

The EVac 70 plasma wand was used in the endoscopic nasal
and sinus tumor resection. EBL was calculated intraoperatively
by the surgeon and anesthetic team using estimates by meas-
uring blood in the suction bottle and on surgical sponges. The
amount of irrigation solution used was then subtracted from
the amount in the suction bottle. Operative time was recorded
from patient electronic data sheets, which routinely record thea-
ter time (from entry to theater, time to incision, and time to
closure) for all surgical procedures. The data were then tabu-
lated (Table I).
The EVac 70 plasma wand uses a bipolar radiofrequency-
based plasma process. Radiofrequency energy excites electro-
lytes in a conductive medium, such as saline, creating precisely
focused plasma. The energized particles in the plasma have suf-
ficient energy to break molecular bonds, excising or dissolving
tissue at a relatively low temperature, thereby preserving the
integrity of surrounding tissue.1 The coblator operates at
between 40
C and 70
C.2 Working at lower temperatures elimi-
nates the risk of an airway fire, even in an unprotected airway,
and causes less collateral damage to surrounding tissues, thus

Fig. 1. Histological appearance of

glomangiopericytoma. Note the
bland cells, regularly arranged
around vascular spaces showing
strong expression of vimentin and
patchy expression of smooth mus-
cle actin (SMA). There were no
other positive immunohistochemical
findings. (A) Hematoxylin and eosin
(H&E) 10. (B) H&E 40. (C) Immu-
nohistochemistry, vimentin, 40. (D)
Immunohistochemistry, SMA, 40.
Note strong staining in vessel walls
(!) and weak, patchy staining in
tumor cells (a). [Color figure can be
viewed in the online issue, which is
available at wileyonlinelibrary.com.]

Laryngoscope 122: February 2012 Syed et al.: Management of Intranasal and Sinus Tumors
437

being potentially safer than electrocautery, which operates at
temperatures of 400
C to 600
C.2 The coblator wand is able to
ablate and coagulate using two separate foot pedals eliminating
the need to change instruments. The precise arrangement of
electrodes and lower temperatures used in radio frequency
coblation mean that collateral damage to the surrounding tis-
sues is negligible.
RESULTS
There were 15 patients with sinus and or intranasal
sinus tumors treated by the senior author between
November 2008 and November 2010. Radiofrequency
coblation was used in the endoscopic resection of all
these cases. Their average age was 50.2 years (range,
17–75 years). Patient demographics, diagnosis, and type
of procedure are shown in Table I. The EBL ranged from
<200 mL to <600 mL. This variation can be explained
by different sizes, grades, extents, and vascularity of
tumors.
For the more vascular tumors, such as angiofibroma
(where average blood loss can range from 1040 mL to
5380 mL in embolized vs. nonembolized patients using
conventional resection techniques3) and rare sinonasal
tumors such as glomangiopericytoma (Figs. 1 and 2), our
average blood loss for the vascular tumors (capillary
hemangioma, angiofibroma, glomangiopericytoma,
hemangiopericytoma) was <400 mL.
Endoscopic view of coblation-assisted resection of
glomangiopericytoma is shown in Figure 3. This patient
developed a cerebrospinal fluid leak intraoperatively
Laryngoscope 122: February 2012
438
Fig. 2. Coronal and axial computed
tomography scans showing opacifi-
cation of the right nasal cavity,
which was diagnosed to be a
glomangiopericytoma.
from the cribriform plate, which was repaired at the
same time using a mucosal flap from the inferior turbi-
nate. Two of the seven patients with inverted papilloma
had been treated with endoscopic resections without
coblation before, and the patient with the transitional
cell carcinoma developed recurrence 3 months after the
primary procedure and successfully underwent a revi-
sion procedure.
DISCUSSION
The use of radiofrequency coblation technology in
otolaryngology was first introduced for adenoid/tonsil
and turbinate reduction surgery and has been rapidly
evolving. In rhinology, the coblator has since been used
for sinonasal polyposis4 and more recently nasopharyn-
geal angiofibromas.5 There is only one other case series
that recently reported the use of radiofrequency cobla-
tion endoscopic resection of intranasal and sinus tumors
in 10 patients.6
Most tumors of the nose and sinuses have a robust
vascular supply, commonly causing profuse bleeding
with techniques such as the microdebrider. However, the
potential for blood loss with coblation radio frequency is
minimal. Small blood vessels seal themselves with the
coblation setting, and larger vessels can be coagulated
by pressing the coagulation pedal if needed. The bipolar
cauterization function of the device is very useful for
cauterizing the anterior and posterior ethmoid arteries
and any feeding vessels. Kostrzewa et al.6 used the
Fig. 3. Preoperative and postopera-
tive endoscopic view of a tumor
that was resected with endoscopic-
aided coblation. [Color figure can
be viewed in the online issue, which
is available at wileyonlinelibrary.com.]
Syed et al.: Management of Intranasal and Sinus Tumors
device in 10 patients with tumors of the sinus and nasal
cavities and showed through their data that the coblator
was associated with significantly lower blood loss (350
vs. 1,000 mL; P ¼ .00001); they estimated blood loss di-
vided by operative time (66 vs. 166 mL/hour; P ¼ .0001)
and Wormald grade (3.3 vs. 6.4; P ¼ .0001) compared to
the microdebrider.
The limitations of the coblator are largely caused by
the size of the wand and the saline delivery system. The
function of the coblator depends on the presence of a
conductive medium. Often when using the device in the
sinus and the nasal cavities, especially the anterior skull
base, the device must be held horizontally. This position-
ing reduces the presence of the conductive medium and
causes a reduction in the effectiveness of the device. In
most instances this can be overcome by increasing the
irrigation delivered.7
To overcome the problem with the size of the
wand, the PROcise EZ plasma wand (ArthroCare) was
tried. The shaft width of the wand is 50% less than the
EVac 70 wand. Although this increased surgical visual-
ization, the senior author found the saline irrigation
system unsatisfactory compared to the Evac 70 wand,
particularly when using the wand in the vertical posi-
tion. There are also different wands now available like
the PROcise XP Plasma wand (ArthroCare), which can
be adjusted to accommodate variable patient anatomy.
The only other published study describing the use of
radiofrequency coblation for endoscopic resection of
sinonasal and skull base tumors in 10 cases concluded
that this technique was associated with significantly
decreased blood loss and was a useful tool in the arma-
mentarium of the endoscopic skull base surgeon.6
There are no other published studies on nasal and
sinonasal tumors describing the use of radiofrequency
coblation.
There has been one other study using this tech-
nique for the resection of head and neck malignancies.8
This report compared 20 case-matched cases of head and
neck cancers treated with radiofrequency coblation to
CO2 laser and concluded that radiofrequency coblation
was an attractive technique for endoscopic resection of
selected upper aerodigestive tract malignancies.
Laryngoscope 122: February 2012
Our study was limited by its small sample size and
its retrospective nature. Comparing the EBL and OT
between the tumors was difficult because of the variabil-
ity of the tumor size invasion and vascularity. Intranasal
tumors are rare entities, and the only way to obtain a
large sample size would be to perform a prospective,
multicenter study over a longer period of time, which
would then enable larger numbers in each tumor sub-
type and ideally compare it to open resection or
microdebrider-assisted resection.
CONCLUSION
Our early experience has demonstrated that radio-
frequency coblation is a useful and safe tool in the
endoscopic management of a range of intranasal and
sinus tumors of differing vascularity and resection diffi-
culty. The EBL was low for most tumors as was the OT.
Our experience was the only reported study of its kind
done in the United Kingdom, and we aimed to share our
early experience of radio frequency coblation in the man-
agement of intranasal and sinus tumors. In the senior
author’s experience, coblation proved to be an invaluable
tool for tumor resection and debulking in the nose and
paranasal sinuses.
BIBLIOGRAPHY
1. Chinpairoj S, Feldman MD, Saunders JC, et al. A comparison of monopolar
electrosurgery to a new multipolar electrosurgical system in a rat
model. Laryngoscope 2001;111:213–217
2. Palmer JM. Bipolar radiofrequency for adenoidectomy. Otolaryngol Head
Neck Surg 2006;135:323–324.
3. Moulin G, Chagnaud C, Gras R, et al. Juvenile nasopharyngeal angiofi-
broma: comparison of blood loss during removal in embolized group ver-
sus nonembolized group. Cardiovasc Intervent Radiol 1995;18:158–161.
4. Eloy JA, Walker TJ, Casiano R, et al., Effect of coblation polypectomy on
estimated blood loss in endoscopic sinus surgery. Am J Rhinol Allergy
2009;23:535–539.
5. Douglas R, Wormald PJ. Endoscopic surgery for juvenile nasopharyngeal
angiofibroma: where are the limits? Curr Opin Otolaryngol Head Neck
Surg 2006;14:1–5.
6. Kostrzewa JP, Sunde J, Riley KO, et al. Radiofrequency coblation decreases
blood loss during endoscopic sinonasal and skull base tumor removal.
ORL J Otorhinolaryngol Relat Spec 2010;72:38–43.
7. Virgin FW, Bleier BS, Woodworth BA. Evolving materials and techniques
for endoscopic sinus surgery. Otolaryngol Clin North Am 2010;43:
653–672, xi.
8. Carney AS, Timms MS, Marnane CN, Krishnan S, Rees G, Mirza S. Radio-
frequency coblation for the resection of head and neck malignancies.
Otolaryngol Head Neck Surg 2008;138:81–85.
Syed et al.: Management of Intranasal and Sinus Tumors
439