Relevance of Cold Steel Tonsillectomy in the Modern Surgical Era: A Case Series of Four Patients with Evaluation of Postoperative Pain and Clinical Outcomes

Abstract

Background: Cold steel dissection tonsillectomy represents the oldest and most widely practiced technique in otorhinolaryngology. Despite the proliferation of energy-based modalities, cold steel dissection continues to be utilized in resource-limited tertiary referral centers, particularly in low- and middle-income countries (LMICs). Objective: To document and evaluate the perioperative safety profile and short-term clinical outcomes of cold steel dissection tonsillectomy in four consecutive patients at RS Bintang Amin, Bandar Lampung, Indonesia. Case Presentations: Four patients (age range 11–27 years; 3 females, 1 male) underwent cold steel dissection tonsillectomy or combined tonsilloadenoidectomy under general anesthesia (June 9–23, 2026). Indications included bilateral tonsillar hypertrophy grade T3–T4, chronic recurrent tonsillitis, halitosis, and sleep-disordered breathing. No intraoperative complications or immediate hemorrhage occurred. Discussion: Current evidence confirms that cold steel dissection produces secondary hemorrhage rates significantly lower than hot dissection techniques, with bipolar diathermy carrying an odds ratio of 2.47 compared to cold steel in the National Prospective Tonsillectomy Audit (n = 40,514). Multimodal analgesia combining paracetamol, NSAIDs, and corticosteroids provided effective postoperative pain control. Conclusion: Cold steel dissection tonsillectomy remains clinically relevant, safe, and effective in the modern surgical era, particularly in LMIC settings.