Comparative Evaluation of Cold Dissection (Suture vs. Ligation) and Hot Dissection Tonsillectomy in Children: Postoperative Pain, Bleeding, and Operative Time

<b>Objectives</b><i>:</i> Tonsillectomy is among the most frequently performed pediatric ENT procedures. Post-tonsillectomy pain and hemorrhage remain key determinants of postoperative morbidity and may differ by surgical technique. This work's objective is to compare postoperative pain, bleeding, and operative duration across three pediatric tonsillectomy techniques: cold dissection with suturing, cold dissection with ligation, and hot dissection with bipolar cautery. <b>Materials and Methods</b><i>:</i> In this single-center, prospective study, 150 children (<i>n</i> = 50 per group) undergoing tonsillectomy (with adenoidectomy) between October 2022 and October 2024 were assigned preoperatively to the following groups: Group 1-cold dissection + suturing; Group 2-cold dissection + ligation; Group 3-hot dissection (bipolar cautery). Pain was assessed with the Wong-Baker FACES scale at 1, 6, and 24 h, days 3 and 7, and with the Parents' Postoperative Pain Measure (PPPM) at 1, 6, and 24 h. Primary bleeding was defined within 24 h; secondary bleeding was within 2 weeks. Operative time was recorded from first incision to hemostasis. Non-parametric tests and chi-square analyses were used with <i>p</i> < 0.05 considered significant. <b>Results</b><i>:</i> Of 150 patients, 58% were male. No primary hemorrhage occurred. Secondary hemorrhage occurred in 4/150 (2.7%): 1/50 (2%) in Group 1, 0/50 (0%) in Group 2, and 3/50 (6%) in Group 3 (overall <i>p</i> > 0.05). Readmission for oral-intake difficulty occurred in 4/150 (2.7%): 1/50 (2%) in Group 1 and 3/50 (6%) in Group 3 (<i>p</i> > 0.05). Operative time differed significantly across groups (Kruskal-Wallis <i>p</i> < 0.05), being longest in Group 1 and shortest in Group 3 (17.53 ± 1.26 min); Group 2 averaged 18.60 ± 0.94 min and Group 1 21.89 ± 1.64 min. Pain decreased over time in all groups (Friedman <i>p</i> < 0.001). Across virtually all time points, Group 2 (ligation) had significantly lower Wong-Baker and PPPM scores than Groups 1 and 3 (Dunn post-hoc, adjusted <i>p</i> < 0.05), while Groups 1 and 3 did not differ consistently. <b>Conclusions</b>: Cold dissection with ligation yielded the most favorable pain profile while maintaining low bleeding rates; hot dissection minimized operative time but tended toward higher secondary bleeding and postoperative intake difficulties. Technique selection should prioritize postoperative comfort and morbidity reduction-particularly in pediatric populations-favoring cold dissection, with ligation offering a consistent analgesic advantage.