Dissection versus diathermy for tonsillectomy

Environmental Impact of Adult Tonsillectomy: Life Cycle Assessment and Cost Comparison of Techniques

OBJECTIVES

To quantify and compare the cost and environmental impact of different techniques for adult tonsillectomy surgery, and to identify target areas for impact reduction.

METHODS

Fifteen consecutive adult tonsillectomy surgeries were prospectively randomized to one of three tonsillectomy techniques: cold, monopolar electrocautery, or low-temperature radiofrequency ablation (Coblation). Life cycle assessment was used to comprehensively evaluate the environmental impact of study surgeries. Outcomes assessed included multiple measures of environmental impact, including greenhouse gas (GHG) emissions, and cost. Environmental impact measures were analyzed to identify highest-yield areas for improvement, and outcomes were compared between surgical techniques using statistical analysis.

RESULTS

GHG emissions for cold, monopolar electrocautery, and Coblation techniques were 157.6, 184.5, and 204.7 kilograms of carbon dioxide equivalents (kgCO2 -eq) per surgery, respectively, with costs totaling $472.51, $619.10, and $715.53 per surgery, respectively. Regardless of surgery technique, anesthesia medications and disposable equipment contributed most to environmental harm. Cold technique demonstrated reduced environmental impact related to disposable surgical equipment in the categories of greenhouse gas emissions, acidification of soil and water, eutrophication of air, ozone depletion, release of carcinogenic, and non-carcinogenic toxic substances, and respiratory pollutant production (p < 0.05 for all comparisons with other techniques).

CONCLUSION

Within the boundaries of operating room processes, cold technique minimizes cost and environmental impact of adult tonsillectomy surgery, with statistical significance noted in the impact of disposable surgical equipment. Areas of highest potential for improvement identified include reducing use of disposable equipment and collaboration with the Anesthesiology care team to streamline medication use.

LEVEL OF EVIDENCE

2, randomized trial Laryngoscope, 134:622-628, 2024.

Comparative Study of Bipolar Electrocautery Versus Silk Ligation for Hemostasis During Tonsillectomy

Tonsillectomy is a commonly performed surgery in otolaryngological practice. Owing to the possibility of postoperative bleeding, it is considered as one of the major surgical procedures. Various techniques have been advocated, however dissection and electrocautery are the most commonly used techniques in tonsillectomy. The objective was to study and compare the relative efficacy using two methods of tonsillectomy- bipolar electrocautery versus silk ligation. This prospective study included 50 patients who underwent tonsillectomy. Patients were randomly divided into two groups. In Group A, left tonsillar fossa haemorrhage was controlled by ligation, while in Group B, bipolar diathermy was used to control bleeding of right tonsillar fossa. Comparison was done in terms of time taken for hemostasis, amount of intra-operative blood loss and post-operative pain. 130 (72.22%) male and 50 (27.77%) females were included. Group A included 20 cases while Group B included 30 cases. The mean time taken for hemostasis in Group A patients was 40.5 ± 4.4 min as compared to 25.3 ± 6.2 min in Group B patients. The mean blood loss on cautery side was 49.5 ± 4.5 ml and that on the ligation side was 68.6 ± 5.3 ml. Post-operative pain was significantly more in Group B patients as compared to Group A patients. Bipolar diathermy is a quicker and faster method to achieve hemostasis with little intraoperative blood loss as compated to silk ligation.

Comparison of three common tonsil surgery techniques: cold steel with hot hemostasis, monopolar and bipolar diathermy

PURPOSE

To analyze the risk of postoperative hemorrhage in tonsil surgery with different surgical methods, instruments, indications, and age groups. Monopolar diathermy compared to bipolar diathermy was of particular interest.

METHODS

The data from tonsil surgery patients were retrospectively collected between 2012 and 2018 in the Hospital District of Southwest Finland. The surgical method, instruments, indication, sex and age and their association with a postoperative hemorrhage were analyzed.

RESULTS

A total of 4434 patients were included. The postoperative hemorrhage rate for tonsillectomy was 6.3% and for tonsillotomy 2.2%. The most frequently used surgical instruments were monopolar diathermy (58.4%) cold steel with hot hemostasis (25.1%) and bipolar diathermy (6.4%) with the overall postoperative hemorrhage rates 6.1%, 5.9% and 8.1%, respectively. In tonsillectomy patients, the risk for a secondary hemorrhage was higher with bipolar diathermy compared to both monopolar diathermy (p = 0.039) and the cold steel with hot hemostasis technique (p = 0.029). However, between the monopolar and the cold steel with hot hemostasis groups, the difference was statistically non-significant (p = 0.646). Patients aged > 15 years had 2.6 times higher risk for postoperative hemorrhage. The risk of a secondary hemorrhage increased with tonsillitis as the indication, primary hemorrhage, tonsillectomy or tonsillotomy without adenoidectomy, and male sex in patients aged ≤ 15 years.

CONCLUSION

Bipolar diathermy increased the risk for secondary bleedings compared to both monopolar diathermy and the cold steel with hot hemostasis technique in tonsillectomy patients. Monopolar diathermy did not significantly differ from the cold steel with hot hemostasis group regarding the bleeding rates.

Coblation Versus Cold Dissection Tonsillectomy: A Comparative Study

Tonsillectomy is the most frequently performed surgery in the recent years. Many techniques have been advocated to improve surgical efficacy and decrease postoperative morbidity. Probably the most update was coblation tonsillectomy. This is a comparative study which was conducted on 50 patients (23 females and 27 males) who underwent tonsillectomy operations, 25 patients using cold steel dissection method whereas coblation technique was used for the rest 25 patients. Follow up was done at day 1, 3, 7 and 14 and the related parameters were calculated. The mean age of patients was 11.6 years with a mean of 2.2-40 years. There were 27 (54%) males out of 50 and 23 (46%) were females. Male to female ratio was 54%:46% ≈ 1.17:1. The current study revealed significant difference between coblation versus cold dissection tonsillectomy. Postoperative pain was significantly less at day 3 and day 7 using coblation technique. Moreover, there were less intraoperative bleeding, less time in days to return to normal diet and less time to return to normal activities. We believe that coblation tonsillectomy carries less morbidity than cold steel dissection, hence we recommend it to be applied at our hospital.

The effect of antibiotics on post-adenotonsillectomy morbidity in Tanzanian children: study protocol for a randomized, double-blind, placebo-controlled trial

BACKGROUND

Adenotonsillectomy is the most frequently performed operation in children worldwide. For decades, prophylactic antibiotics have been prescribed to limit postoperative complications. The effect of this antibiotic use has been refuted in a Cochrane Review. However, all reviewed studies were carried out in developed countries. In Tanzania, like many other developing countries with limited resources and a high burden of infectious diseases, postoperative antibiotic prescription is still very common to decrease the supposed higher postoperative morbidity. However, as a consequence of this widespread use of postoperative antibiotics, cross-resistance and risk of allergic side effects rise. Well-designed randomized controlled trials are needed to limit unnecessary antibiotic prescription and secondary antibiotic resistance.

AIM

The aim of this study is to analyse the prophylactic role of postoperative antibiotics on morbidity following adenotonsillectomy in children in Tanzania.

DESIGN

The double-blinded, randomized, placebo-controlled trial was set in northern Tanzania. Participating centres are the Department of Otolaryngology at Kilimanjaro Christian Medical Centre in Moshi and the Department of Paediatric Surgery at the Arusha Lutheran Medical Centre in Arusha.

METHODS

Around 270 children aged 2-14 years, all scheduled for elective (adeno)tonsillectomy, will be included and assigned to receive either a standard regimen of 5 days of antibiotic prophylaxis or placebo after surgery. The primary outcomes are postoperative haemorrhage, fever and pain. Secondary outcomes are the time until normal diet is resumed, the time until normal activities are resumed and the occurrence of adverse events and microbial recolonization of the tonsillar beds.

DISCUSSION

This study will enhance an increase of proper antimicrobial prescription in Tanzanian institutions as well as other resource-limited countries where prescription of antibiotics is still very common. In addition, it might augment current knowledge about surface and core tonsillar micro-organisms and sensitivity patterns.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR201905466349317. Retrospectively registered on 15 May 2019. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=8119.

Harmonic Scalpel Versus Coblation Tonsillectomy A Comparative Study

Tonsillectomy is an age old procedure in ENT practice. Though traditional dissection method is gold standard, we surgeons are trying different techniques like electrocautery, coblation, harmonic scalpel (HS) mainly to improve surgical convenience, to decrease operative time, post operative pain, intra and post operative bleeding and fast return to normal life. In this particular study we are comparing coblation and HS as surgical tool in tonsillectomy. It is a prospective double-blind randomized controlled trial where information was compared between two groups of coblation and HS tonsillectomy. A total number of 128 patients were compared over operation time, intra-operative blood loss, postoperative pain, time needed to regain the normal diet and activity and postoperative haemorrhage. We found statistically significant differences in operation time (p < 0.001) and intra operative blood loss (p < 0.001). Secondary haemorrhage rate was far better in HS (1.5%) group compared to coblation (7.8%). Whereas postoperative pain, time needed to go back to the normal diet and activity were better in HS group but the difference is not significant. This study revealed a significantly less operative time and intra-operative and post operative blood loss in harmonic scalpel tonsillectomy in comparison with coblation method. These findings addressed HS tonsillectomy as an advanced method.

Coblation tonsillectomy versus coblation tonsillectomy with ties in adults

Objective

This study was performed to compare the intraoperative and postoperative courses of coblation tonsillectomy and coblation tonsillectomy with ties in adults.

Methods

All patients who underwent tonsillectomy from July 2012 to September 2016 were retrospectively reviewed. Intraoperative and postoperative bleeding, pain, and return to normal food intake were compared between patients who underwent coblation tonsillectomy and those who underwent coblation tonsillectomy with ties.

Results

Of 515 patients, 300 (58.3%) underwent coblation tonsillectomy and 215 (41.7%) underwent coblation tonsillectomy with ties. Twenty-five (4.9%) patients developed postoperative hemorrhage, 22 (88.0%) of whom had undergone coblation tonsillectomy and 3 (12.0%) of whom had undergone coblation tonsillectomy with ties. Patients who underwent coblation tonsillectomy reported less pain than those who underwent coblation tonsillectomy with ties. Patients who underwent coblation tonsillectomy with ties resumed a normal diet significantly later than those who underwent coblation tonsillectomy (10.0 ± 3.2 vs. 8.2 ± 1.9 days, respectively).

Conclusion

Coblation tonsillectomy is associated with less intraoperative bleeding, a shorter surgery time, less postoperative pain, and fewer days to recovery of a normal diet than is coblation tonsillectomy with ties. However, coblation tonsillectomy with ties is associated with remarkably reduced postoperative hemorrhage.

Comparative Post-operative Pain Analysis Between Coblator Assisted and Bipolar Diathermy Tonsillectomy in Paediatric Patients

Tonsillectomy is one of the commonly performed otolaryngological operations. Despite a range of different techniques post-operative pain remains a major side-effect of this operation. Coblation assisted tonsillectomy is a latest technique of tonsillectomy. This technique is said to be associated with less intra-operative bleeding and less postoperative morbidity. We conducted a study in 100 patients to compare the pain scores between coblation assisted and bipolar diathermy tonsillectomy by FLACC score and Wong Baker scale score. The data so collected was statistically analysed using a t test and p values were calculated. The p value was highly significant (p < 0.001) for both scores in coblation assisted tonsillectomy 6 h postoperatively and on 1st postoperative day (p < 0.05). On 7th post-operative day however there was no significant difference in post-operative pain score using FLACC score in both groups but Wong baker scale scores were still significant. We concluded that post-operative pain was less with coblator assisted tonsillectomy as compared to bipolar diathermy tonsillectomy at least in early post-operative period.

The comparison of bleeding and pain after tonsillectomy in bipolar electrocautery vs cold dissection

OBJECTIVE

Although tonsillectomy is one of the most common surgeries performed in pediatric, it has potential major complications such as pain and bleeding. This study aimed to compare the bleeding and pain after tonsillectomy in bipolar electrocautery tonsillectomy versus cold dissection.

METHODS

This double blind clinical trial was conducted on 70 pediatric patients who were candidate of tonsillectomy. Patients were divided into two groups of including bipolar cautery (BC) and cold dissection (CD). operation time, intraoperative blood loss, and postoperative bleeding and pain were evaluated in the current study.

RESULTS

In both of the CD and BC groups, no significant difference was found in terms of sex and age. The average amount of the intraoperative blood loss in BC group was 14.086 ± 5.013 ml and in CD group was 26.14 ± 4.46 ml (p. v = 0.0001). The mean time of operation in BC group was 19 ± 2.89 min and in CD group was 29.31 ± 5.29 min (p. v = 0.0001). patients were evaluated in terms of pain on the first, third, fifth, and seventh days after the operation. No statistically significant difference was found between two groups. Moreover, Compared pain scores in all times across two groups, no significant difference was found. In terms of postoperative bleeding, none of the patients in both groups had bleeding during follow-up.

CONCLUSION

Our study showed that bipolar electrocautery tonsillectomy can significantly reduce the operation time and intraoperative blood loss; however, postoperative pain and blood loss were similar in both techniques. We recommend bipolar electrocautery as the most suitable alternative method for tonsillectomy, especially in children.

Inter-Hospital Variability of Postoperative Pain after Tonsillectomy: Prospective Registry-Based Multicentre Cohort Study

Objectives

Although tonsillectomy is one of the most frequent and painful surgeries, the association between baseline and process parameters and postoperative pain are not fully understood.

Methods

A multicentre prospective cohort study using a web-based registry enrolled 1,527 women and 1,008 men aged 4 to 85 years from 52 German hospitals between 2006 and 2015. Maximal pain (MP) score the first day after surgery on a numeric rating scale (NRS) from 0 (no pain) to 10 (MP) was the main outcome parameter.

Results

The mean maximal pain score was 5.8±2.2 (median 6). Multivariable analysis revealed that female gender (Odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12 to 1.56; p = 0.001), age <20 years (OR = 1.56; CI = 1.27 to 1.91; p<0.0001), no pain counselling (OR = 1.78; CI = 1.370 to 2.316; p<0.001), chronic pain (OR = 1.34; CI = 1.107 to 1.64; p = 0.004), and receiving opioids in recovery room (OR = 1.89; CI = 1.55 to 2.325; p<0.001) or on ward (OR = 1.79; CI = 1.42 to 2.27; p<0.001) were independently associated with higher experienced maximal postoperative pain (greater the median of 6). The effect of age on pain was not linear. Maximal pain increased in underage patients to a peak at the age of 18 to 20 years. From the age of ≥20 years on, maximal pain after tonsillectomy continuously decreased. Even after adjustment to all statistically important baseline and process parameters, there was substantial variability of maximal pain between hospitals with a heterogeneity variance of 0.31.

Conclusion

Many patients seem to receive insufficient or ineffective analgesia after tonsillectomy. Further research should address if populations at risk of higher postoperative pain such as females, younger patients or those with preexisting pain might profit from a special pain management protocol. Beyond classical demographical and process parameters the large variability between different hospitals is striking and indicates the existence of other unknown factors influencing postoperative pain after tonsillectomy.

What Are the Trends in Tonsillectomy Techniques in Wales? A Prospective Observational Study of 19,195 Tonsillectomies over a 10-Year Period

There are a multitude of techniques to undertake tonsillectomy, with hot techniques such as diathermy and coblation being associated with a higher risk of secondary haemorrhage. The UK National Prospective Tonsillectomy Audit (2004) advocated cold steel dissection and ties to be the gold standard. This prospective observational study investigates the trends in tonsillectomy techniques across Wales in the last decade to establish if surgeons have adhered to this national guidance. Data relating to tonsillectomy were extracted over a 10-year period from 1 January 2003 to 31 December 2012 from the Wales Surgical Instrument Surveillance Programme database. A total of 19,195 patients were included. Time-series analysis using linear regression showed there was an increase in the number of bipolar diathermy tonsillectomies by 84% (Pearson's r = 0.762, p = 0.010) and coblation tonsillectomies by 120% (r = 0.825, p = 0.003). In contrast, there was a fall in the number of cold steel dissection tonsillectomies with ties by 60% (r = −0.939, p < 0.001). This observational study suggests that the use of bipolar and coblation techniques for tonsillectomy has increased. This deviation from national guidance may be due to these techniques being faster with less intraoperative bleeding. Further study for the underlying reasons for the increase in these techniques is warranted.

Post-tonsillectomy complications in children less than three years of age: a case-control study

OBJECTIVES

To assess the need for post-tonsillectomy admission in children under the age of three years.

DESIGN

A retrospective case-control study.

METHOD

Medical records of 127 children under the age of three years who underwent tonsillectomy with or without adenoidectomy were reviewed for complications and compared to 127 gender-matched controls between three to four years of age.

RESULTS

Overall complication rate in the study group was 9.4% (12 of 127). Early complications (3.1%) were respiratory related, while late complications (6.3%) were due to dehydration and hemorrhage. Comparable complication rate was observed in the control group (8.7%, P>0.05); early complication rate of 3.1% and late complication rate of 5.5% was ascertained. Similar types of complications occurred in the control group.

CONCLUSIONS

Post-tonsillectomy complication rates were low and no significant difference was observed between the study and control groups. This suggests that postoperative admission for children younger than three years of age may not be necessary in all cases.

Pain management for pediatric tonsillectomy: an integrative review through the perioperative and home experience

PURPOSE

This integrative review aims to increase our understanding of current pain management care practices for children undergoing tonsillectomy.

CONCLUSIONS

Synthesis of the literature resulted in four main opportunities for care providers to manage pain: preoperative education and preparation, intraoperative surgical interventions, and postoperative pharmacologic and nonpharmacologic interventions in the post anesthesia care unit and home settings.

PRACTICE IMPLICATIONS

Nurses have many opportunities to understand pain management practices and intervene to minimize pain experienced in pediatric outpatients undergoing tonsillectomy.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011.Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period.

OBJECTIVES

To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013.

SELECTION CRITERIA

We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre- and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently.

MAIN RESULTS

We included seven trials (593 participants; 397 children and 196 adults). The period of follow-up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage.

AUTHORS' CONCLUSIONS

Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data.

Six years of evidence-based adult dissection tonsillectomy with ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection

OBJECTIVE

To conduct an adequately powered, prospective, randomised, controlled trial comparing adult dissection tonsillectomy using either ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection.

METHODS

Three hundred patients were randomised into four tonsillectomy technique groups. The operative time, intra-operative bleeding, post-operative pain, tonsillar fossa healing, return to full diet, return to work and post-operative complications were recorded.

RESULTS

The bipolar radiofrequency group had a shorter mean operative time. The mean intra-operative blood loss during bipolar radiofrequency tonsillectomy was significantly less compared with cold dissection and ultrasonic scalpel tonsillectomy. Pain scores were significantly higher after bipolar electrocautery tonsillectomy. Patients undergoing bipolar electrocautery tonsillectomy required significantly more days to return to full diet and work. The bipolar electrocautery group showed significantly reduced tonsillar fossa healing during the first and second post-operative weeks.

CONCLUSION

In this adult series, bipolar radiofrequency tonsillectomy was superior to ultrasonic, bipolar electrocautery and cold dissection tonsillectomies. This method combines the advantages of 'hot' and 'cold' tonsillectomy.

Consenting for risk in common ENT operations: an evidence-based approach

Pre-operative consent discussion and documentation is an essential process that should follow relevant guidance, and include all serious or frequently occurring risks. We assessed the appropriateness of consent for grommet insertion, tonsillectomy, septoplasty, and hemithyroidectomy, by comparing the risks listed in current consenting practice to published complication data for the relevant operation. 120 consent forms and associated clinic letters were analysed. A literature search identified published complication data for comparison. There was great variation in consent practice for each operation type, and poor correlation with published risk incidence. Only 'bleeding' post-tonsillectomy and 'recurrent laryngeal nerve injury' post hemithyroidectomy were listed in 100 % of relevant cases. Common and serious complications were frequently omitted from forms. The number and type of risks consented for a procedure significantly differed between consultant and non-consultant staff. The potential requirement for blood transfusion was discussed in only 20 % of tonsillectomy cases. Currently, the pre-operative consent for commonly performed ENT operations does not reflect operative risks. Consenting for surgical complications should be evidence based using published or personal data. A change in the consent process is required to protect patient autonomy and meet both legal and professional body requirements.

Coblation versus traditional tonsillectomy: A double blind randomized controlled trial

BACKGROUND

Coblation tonsillectomy is a new surgical technique and demands further research to be proven as a suitable and standard method of tonsillectomy. This study compares coblation and traditional tonsillectomy techniques in view of their advantages and complications.

METHODS

In a prospective double-blind randomized controlled trial information on operation time, intraoperative blood loss, postoperative pain, time needed to regain the normal diet and activity and postoperative hemorrhage were gathered and compared between two groups containing 47 patients in each group.

RESULTS

We found statistically significant differences in operation time (p < 0.05), intraoperative blood loss (p < 0.05), postoperative pain (p < 0.001), time needed to find back the normal diet (p < 0.001) and normal activity (p < 0.001). However, post operation hemorrhage (p > 0.5) was not significantly different between two groups.

CONCLUSIONS

This study revealed a significantly less intraoperative or postoperative complications and morbidity in coblation tonsillectomy in comparison with traditional method. Coblation was associated with less pain and quick return to normal diet and daily activity. These findings addressed coblation tonsillectomy as an advanced method.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2010.Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period.

OBJECTIVES

To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 22 April 2011.

SELECTION CRITERIA

We included randomised controlled trials in which mouthwashes, used pre- and postoperatively, have been compared with placebo.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently.

MAIN RESULTS

We included six trials (528 participants; 397 children and 131 adults). The period of follow up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain but only until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage.

AUTHORS' CONCLUSIONS

The risk of bias was high in most of the included trials and poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data.