Patient reported pain-related outcome measures after tonsil surgery: an analysis of 32,225 children from the National Tonsil Surgery Register in Sweden 2009-2016

Pain after Licorice or Sugar-Water Gargling in Patients Recovering from Oropharyngeal Surgery-A Randomized, Double-Blind Trial

BACKGROUND

Glycyrrhiza glabrata (licorice) is used in traditional medicine and herbal remedies and reduces sore throats consequent to intubation, but whether it is protective for more intense pain after oropharyngeal surgery remains unclear. We thus tested the joint hypothesis that gargling with licorice, which has anti-inflammatory and antioxidant properties, reduces postoperative pain and morphine consumption.

METHODS

We enrolled patients having elective oropharyngeal surgery. Participants were randomly allocated to gargle with either 1 g licorice or a sugar placebo before and for up to three days after surgery. A numerical rating scale (NRS) for pain along with morphine consumption was evaluated every 30 min during the post-anesthesia care unit (PACU) stay and then three times daily for three days. We pre-specified that licorice gargling would be deemed better than sugar gargling only if found non-inferior on both morphine consumption and pain score and superior on at least one of the two.

RESULTS

65 patients were randomized to the licorice group and 61 to placebo. We found noninferiority (NI) in pain scores with an estimated mean difference of -0.09 (95.2% CI: -0.88, 0.70; p = 0.001; NI delta = 1) between licorice and placebo gargling. There were no adverse events reported in either group that required treatment discontinuation.

CONCLUSIONS

Gargling with licorice did not significantly or meaningfully reduce postoperative pain or morphine consumption in patients recovering from oropharyngeal surgery. While higher doses might prove more effective, our results suggest that other topical analgesics should be considered.

Telephone Counseling for Children Recovering from Tonsil Surgery-A Randomized Controlled Feasibility Study

BACKGROUND

Even though children after tonsil surgery experience pain and other limitations in their daily lives, nursing care is transferred to parents after tonsil surgery, and they might need some kind of support. The aim of the study was to test the design of a randomized controlled trial intended to evaluate a nurse-led telephone follow-up after tonsil surgery on postoperative symptoms and quality of life.

METHODS

Of the seventeen children aged 3-17 years scheduled to tonsil surgery, nine were randomized to the intervention group and eight to the control group using a randomization list. The parents in the intervention group were contacted by telephone on days 1, 3, 5, and 10 postoperatively for counseling by a nurse. The instruments Postoperative Recovery in Children (PRiC) and the health-related quality of life instrument (EQ-5 D-Y) were used to evaluate postoperative symptoms and quality of life, respectively.

RESULTS

Eight participants in the intervention group reported throat pain compared to five participants in the control group on the operation day and four days after, possibly due to an uneven distribution of the type of surgery between the study groups. The parents appreciated the telephone counseling, and there were no unplanned revisits in the intervention group. However, it was difficult to recruit participants and the assessment tools were not always fully completed.

CONCLUSIONS

No explicit conclusions can be drawn from this feasibility study due to the low number of participants and the study design needs adjustments.

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery

OBJECTIVE

The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS).

MATERIALS & METHODS

A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries).

RESULTS

Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy.

CONCLUSION

The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

Tonsillotomy for Periodic Fever Syndrome: A Randomized and Controlled Trial

OBJECTIVE

Tonsillectomy is an effective treatment for periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. Tonsillotomy has a milder operative risk profile and postoperative morbidity in children than tonsillectomy. We aimed to compare the efficacy of tonsillotomy to observation-only in children with PFAPA syndrome at a 3-month follow-up.

METHODS

This was a randomized multicenter trial with sequential design. Participants were randomized into a tonsillotomy group and a control group that was only observed. The trial started in 1/2017 and was accomplished in 12/2021 with 16 patients (10 boys, six girls, the mean age 4.2 years). The symptoms were monitored with daily symptom diaries.

RESULTS

After the 3-month follow-up, 7/8 patients (87.5%) in the tonsillotomy group and 2/8 (25%) patients in the control group were free from PFAPA symptoms (95% CI 13% to 87%; p = 0.0021). The mean number of days with fever was 2.6 (SD 3.7) in the tonsillotomy group and 8.0 (SD 6.5) days in the control group (n = 8) (p = 0.06). Mean number of fever days compatible with PFAPA syndrome was 0.8 (SD 1.4) in the tonsillotomy group and 6.5 (SD 6.0) in the control group (95%CI -10% to -1%; p = 0.007). Rescue tonsillectomy was needed for all patients in the control group and none of the patients in the tonsillotomy group.

CONCLUSIONS

Tonsillotomy might be an effective treatment option for children with PFAPA syndrome. Further studies are needed to clarify the long-term efficacy of tonsillotomy for treating PFAPA.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:968-972, 2024.

The Clinical Significance of Tonsillar Actinomyces in Histopathological Samples after Tonsillectomy

BACKGROUND

Actinomyces is a genus of Gram-positive anaerobic or microaerophilic bacteria with a branched filamentous shape. Their presence in tonsil tissue is usually determined by histopathological examination. In the crypts of removed tonsils, they have a prevalence ranging from 0.8% to 61.6%. The role of Actinomyces in diseases of the palatine tonsils is not clearly defined. The aim of the study was to determine the importance of Actinomyces in the pathology of palatine tonsils and to assess the impact of these bacteria on the clinical data.

METHODS

the retrospective analysis of the histopathological findings of patients undergoing tonsillectomy in our hospital from January 2017 to the end of December 2019 was performed in terms of the occurrence of Actinomyces. The data were collected based on the medical history. The study included 481 patients aged 3-82 years. From the study group, 100 adult patients were randomly selected, and a telephone survey was conducted. The questions included the co-occurrence of bronchial asthma, halitosis, tonsilloliths, and cigarette smoking. The questions were related to the complications following tonsillectomy and the severity of postoperative pain. Existence of a relationship was investigated between occurrence of tonsillar Actinomyces and age, sex, body mass index, and medical condition (obstructive sleep apnea, chronic palatine tonsillitis), respectively. The size of the removed tonsils was assessed and compared depending on the presence of the bacteria.

RESULTS

patients aged 18 years and older had a higher probability of presenting Actinomyces. The estimated odds ratio for the presence of the bacteria per year of age was 1.023 [1.007, 1.041]. No statistically significant results were found for the other variables. The co-occurrence of the bacteria and halitosis was close to statistical significance (p = 0.064).

CONCLUSIONS

multivariate analysis of the role of Actinomyces in tonsillar pathology showed that these microorganisms should be considered saprophytes of the oropharyngeal microflora that had no significant relationship with the pathology of palatine tonsils. Further studies on their influence on halitosis are warranted.

Safety and long-term efficacy of tonsillectomy versus subtotal tonsillectomy in children with sleep disordered breathing

OBJECTIVES

to compare safety and long-term symptoms after TE compared to Subtotal Tonsillectomy (STT).

METHODS

A retrospective review data of 412 patients, one to twelve years old that underwent either TE or STT, as treatment for sleep disorder breathing, at two different medical centers. Symptoms were assessed by a questionnaire 3-5 years post-surgery. Additionally, data regarding immediate post-operative symptoms and complications were also collected.

RESULTS

Long-term symptoms score was significantly lower in the TE group: 1.585 (±1.719) compared to 1.967 (±1.815) in the STT group (p = 0.033); 51.3% of patients in the ST group presented long-term SDB symptoms, compared to 40.6% in the TE group (p = 0.035); The main difference between the groups was snoring as 49% of the STT group suffered from snoring, versus 28.9% in the TE group (p < 0.001).

CONCLUSIONS

TE showed an advantage over STT in resolving snoring in the long term.

A validation study of data in the National Tonsil Surgery Register in Sweden: high agreement with medical records ensures that data can be used to monitor clinical practices and outcomes

BACKGROUND

The ambition of the National Tonsil Surgery Register in Sweden (NTSRS) is to improve otorhinolaryngological care by monitoring trends in the clinical practices, complications, and outcomes of tonsil surgery. The NTSRS collects data from both surgeons and patients and provides the participating clinics with daily updated data on a publicly available website. On the website, national and local results can be compared and monitored. The use of NTSRS data necessitates that the data is valid, but the NTSRS has not yet been validated. With approximately half of the registered patients responding to the postoperative questionnaires, an analysis of responders and non-responders is also necessary. The aim of this study was to assess the criterion validity of NTSRS data. Another aim was to compare the characteristics and rates of complications between postoperative questionnaire responders and non-responders.

METHODS

Data in the NTSRS were compared with data in electronic medical records. The 200 most recent surgeries, up to 31 Dec 2019, in each of 11 surgical units were included. Criterion validity was analysed in terms of observed agreement, Cohens kappa, Gwet's AC₁, and positive and negative agreement. The sign test was used to analyse systematic differences between the NTSRS and the medical records. Comparisons of rates between groups were made with Fisher's exact test, the chi-square test, and Fisher's non-parametric permutation test.

RESULTS

A total of 1991 registrations were included in the study. All variables showed very high observed agreement ranging from 0.91 to 1.00, and all variables had AC₁ values corresponding to almost perfect agreement. The analysis of questionnaire responders and non-responders showed no statistically significant differences regarding age, indication, or type of surgery. The proportion of women was higher in the responder group. The rate of reoperation due to bleeding was higher in the responder group, but there were no differences regarding other complications.

CONCLUSIONS

The results of this study show that data in the NTSRS have criterion validity. The NTSRS is thus well suited for monitoring the clinical practices and outcomes of tonsil surgery. The quality of the data also implies that the registry can be used in both clinical improvement projects and research.

Effect of placebo versus prophylactic postoperative amoxicillin on post-(adeno) tonsillectomy morbidity in Tanzanian children: a two-centre, double-blind randomized controlled non-inferiority trial

INTRODUCTION

to date in Africa, there is limited evidence regarding the role of prophylactic antibiotics to prevent post (adeno) tonsillectomy ((A)TE) morbidity in children. As (A)TE is the most performed surgery in the pediatric population, the use of prophylactic antibiotics is likely a major factor in the development of AMR. In Tanzania, as in many other settings with limited resources antibiotics are misused and overprescribed. Potential reasons include limited stewardship and widespread use of postsurgical prophylactic antibiotics. Misuse of antibiotics might contribute significantly to the development of antimicrobial resistance (AMR).

METHODS

a two-centre, double-blinded randomized controlled non-inferiority trial. Subjects included children from 2-14 years of age with recurrent chronic tonsillitis and/or obstructive sleep apnoea due to adenotonsillar hypertrophy who were electively scheduled for (A)TE in two tertiary hospitals. Participants were randomly allocated to receive either placebo or amoxicillin for five days postoperatively. Primary outcome was non-inferiority of placebo compared with amoxicillin for postoperative haemorrhage (margin 5%; at 14 days) postoperative fever (margin 5%; at 7 days), and pain (margin 1 point; at 7 days). Secondary outcomes included the times required for resumption of normal diet and normal activities, and microbial recolonization of the tonsillar beds. Data were analysed according to intention-to-treat principle. Follow-up was 14 days.

RESULTS

between March 13, 2019 and September 20, 2019 270 children were enrolled. All children were randomly assigned to receive placebo (n = 136) or amoxicillin (n = 134). By 14^{t h}day post-operatively, total of 8 children were lost to follow-up in each arm. No major postoperative haemorrhage was registered. By 14^th day post-operatively, 22 (17.5%) children in the amoxicillin arm and 19 (14.8%) children in the placebo arm had reported minor haemorrhage (risk difference (RD) -2.6% (95%CI -10.2 - 5.0); p_{non-inferiority} = 0.045). By 7^th day post operatively, 8 (6.3%) children in amoxicillin arm and 4 (3.1%) children in placebo arm reported fever during the first week (RD -3.2% (95%CI -7.6 - 1.2); p_{non-inferiority} = 0.001). By 7^th day post operatively, mean pain score (mean (SD)) was 3.25 (1.53) in the amoxicillin arm and 3.56 (1.68) in the placebo arm (mean difference 0.31, (95% CI -0.02 - 0.65); p_{non-inferiority} < 0.001). No statistically significant differences between the two groups were found in any of the secondary outcomes. Findings shows, placebo is non-inferior to amoxicillin for post-operative morbidities in Tanzanian children undergoing (A)TE.

CONCLUSION

it is recommended that antibiotics should only be used when clinically necessary to treat a specific infection. Unnecessary use of antibiotics contributes to the development of antimicrobial resistance. Trial Registration: Pan African Clinical Trials Registry PACTR201905466349317. Retrospectively registered on 15 May 2019.

Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study

OBJECTIVE

Post-tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day-case tonsillectomy.

METHODS

We compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post-tonsillectomy pain. Post-tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post-tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated.

RESULTS

In the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P =  0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post-tonsillectomy bleeding in the two groups was not statistically different.

CONCLUSION

We recommend celecoxib as a more suitable choice than acetaminophen for post-tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.

Monopolar electrocautery tip vs plasma ablation in tonsillotomy: A randomized case-control study comparing outcomes in pediatric population

BACKGROUND

The objective of this study was to compare the low-priced monopolar electrocautery to the high-priced, worldwide used, plasma ablation in tonsillotomy among children aged between three and twelve years, suffering from obstructive breathing disorders (OBD), with respect to post-operative pain, bleeding and related morbidities.

METHODS

A randomized case-control study was conducted in the Eye and Ear Hospital International- Lebanon. 103 children aged between three and twelve years suffering from OBD secondary to tonsillar hypertrophy were randomly assigned into two groups. Post-operative pain was evaluated using age-adequate validated scales: "FLACC-R" (Face, Legs, Activity, Cry, Consolability-Revised) for children aged less than five years, and "Wong Baker faces" for older children. Additional post-operative outcomes were evaluated using Pain-PROM (Patient reported Pain-Related Outcome Measures) and TAHSI (Tonsil and Adenoid Health Status Instrument) scales.

RESULTS

Significantly, higher rates of patients who underwent tonsillotomy via plasma ablation technique used analgesics and had severe pain compared to the monopolar electrocautery group. A longer operative duration was significantly associated with higher pain scores, and the plasma ablation technique yielded significantly higher operative mean durations. 10 days post-operatively, a significantly higher percentage of children reported an overall high pain severity and more than expected overall pain when using the plasma ablation technique compared to the monopolar electrocautery one. Overall bleeding rates were similar. No difference was reported one month post-operatively.

CONCLUSION

When compared to plasma ablation, monopolar electrocautery, can provide the same efficiency in relieving OBD in healthy children, with equal overall bleeding rates, but significantly lower cost, operating time, pain scores and need for analgesics.

The effectiveness of a preoperative multi-component non-pharmacologic preparation on post-tonsillectomy pain: A randomized controlled clinical trial

INTRODUCTION

Tonsillectomy is a painful operation and some studies have suggested that preoperative non-pharmacologic preparations may decrease postoperative pain. In this randomized clinical trial study, we decided to determine which is more effective in the post-tonsillectomy pain; an informative booklet or a costly, time consuming, sophisticated, and multi-component preparation program.

MATERIALS AND METHODS

Patients were randomly assigned into two groups. In the booklet group, children and their parents only received an informative booklet as routine information preparation. On the other hand, in the multi-component group; in addition to receiving the same booklet, children and their parents received our multi-component pre-operative preparation program. The following items were included in the package: preoperative tour in the ward, an educational DVD, and therapeutic play intervention. All patients were observed at least for 8 h as a day case or ambulatory tonsillectomy. The pain score was recorded according to the visual analog scale for seven days. Finally, the post-tonsillectomy pain scores were compared in the two groups. The multi-component group included 121 children and booklet group 120.

RESULTS

Minimum and maximum age was 9 and 12 years. Regarding post-tonsillectomy pain, we found no significant difference between the multi-component group and the booklet group.

CONCLUSION

Our data revealed that a new concept which is more cost-effective and concise booklet is as effective as costly and sophisticated methods in post-tonsillectomy pain among 9-12 years old children.

Addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia improves analgesic efficacy after tonsillectomy and adenoidectomy: A randomized controlled trial

OBJECTIVES

The aim of this study was to determine whether the addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia was more effective than ropivacaine alone in attenuating pain after tonsillectomy and adenoidectomy.

METHODS

This was a double-blind randomized clinical trial. One hundred and twenty children scheduled for tonsillectomy and adenoidectomy using a combination of general anaesthesia and local infiltration anaesthesia were randomized into the dexmedetomidine plus ropivacaine group (DR) and ropivacaine group (R). The children were locally infiltrated with 1 μg kg^-1 dexmedetomidine and 0.25% ropivacaine in the DR group or 0.25% ropivacaine alone in the R group. In both groups, local infiltration anaesthesia was performed using 5 ml of solution. The pain scores were recorded at the 1st, 4th, 8th, 12th, 16th, 20th, and 24th hours after surgery using the Face Legs Activity Cry Consolability (FLACC) scale. When the pain score exceeded 4, paracetamol syrup (15 mg kg^-1) was administered as a rescue analgesic. Time to the first administration of analgesic was recorded.

RESULTS

8th, 16th, 20th, and 24th hours after surgery, the children in the DR group had lower pain scores than those in the R group (P<0.05). The time to the first administration of analgesic was significantly longer in the DR group (mean: 10.4 h, range: 9.4-11.4 h) than in the R group (mean: 8.1 h, range: 7.3-8.8 h) (P < 0.001).

CONCLUSION

The addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia effectively improved the efficacy of analgesia and extended the duration of analgesia after tonsillectomy and adenoidectomy.

Postoperative pain, pain management, and recovery at home after pediatric tonsil surgery

Purpose

To explore the severity and duration of postoperative pain, the management of analgesics, and postoperative recovery in children undergoing tonsil surgery.

Method

Participants included 299 children aged 4–17 years undergoing tonsillotomy ± adenoidectomy (TT ± A) or tonsillectomy ± adenoidectomy (TE ± A). Data were collected up to 12 days. The child rated pain on the Face Pain Scale-Revised (FPS-R) and recovery using the Postoperative Recovery in Children (PRiC) questionnaire. Caregivers assessed their child's pain, anxiety, and nausea on a numeric analog scale and kept a log of analgesic administration.

Results

High pain levels (FPS-R ≥ 4) were reported in all surgical and age groups (TT ± A age 4–11, TE ± A age 4–11, TE ± A age 12–17), but there were variations in pain intensity and duration within and between groups. The TE ± A group scored more days with moderate to very excruciating pain and lower recovery than the TT ± A group, with the worst outcomes reported by older TE ± A children. The majority of the children used paracetamol + COX-inhibitors at home, but regular administration of analgesics was lacking, particularly during late evening and at night. Few were received rescue medication (opioid or clonidine) despite severe pain. Physical symptoms and daily life activities were affected during the recovery period. There was moderate agreement between child and the caregiver’s pain assessment scores.

Conclusion

Children reported a troublesome recovery with significant postoperative pain, particularly older children undergoing tonsillectomy. Pain treatment at home was suboptimal and lacked regular analgesic administration. Patient information needs to be improved regarding the importance of regular administration of analgesics and rescue medication.

The first experiences of implementation of the Swedish tonsil register in Denmark

Background: Tonsil surgery is a daily procedure at Ear, Nose and Throat (ENT) departments as well as ENT practices. Despite national tonsil guidelines in Denmark, no national survey has been introduced.Objectives: To display the process of implementing a Danish version of the Swedish tonsil register including a presentation and validation of the first year's results.Methods: The Swedish tonsil register was translated into Danish. Minor modifications were executed and the register was implemented at the ENT department, Region Hospital West Jutland, Denmark. All patients undergoing surgery due to benign tonsil and/or adenoid diseases were eligible. Written informed consent was obtained. Indication for surgery, comorbidity, surgical and haemostasis techniques, and complications were registered by the surgeon.Results: Several obstacles were encountered due to legal procedures, daily work, IT organisation, and discontinuous information. 58% of eligible patients were registered. The incidence of post-tonsillectomy haemorrhage requiring secondary surgery was 6.4%. The potential underlying risk factors were easily retrieved from the register.Conclusions and significance: The Danish version of the national Swedish tonsil database is a useful, easily accessible, and informative tool for monitoring and validation of tonsil/adenoid surgery. We recommend a nationwide register with a central steering committee.

Comparison of Postoperative Pain and Appetite in Pediatric Patients Undergoing Monopolar Tonsillotomy and Cold Steel Tonsillectomy

Objectives

Adenotonsillectomy (AT) is amongst the most widely performed pediatric surgeries in the United States (US) and the whole world. AT includes two major surgical techniques: total tonsillectomy (TT) and partial tonsillectomy (PT). Several studies have been conducted to evaluate the difference between TT and PT and assess the comparative effectiveness, benefits, and sequelae between both. In Lebanon, very few studies were done tackling this issue and assessing its sequelae on the pediatric population.

Methods

A prospective study was conducted including pediatric patients aged between 2 and 9 years, who were admitted for partial tonsillectomy (PT) or total tonsillectomy (TT) in 2018. An estimated number of children included were 50: 25 patients underwent PT and 25 patients underwent TT. Patients were sent home on day 1 post-op with a questionnaire that evaluates the following over the first 10 days post-op: pain using the Wong–Baker Faces Pain Rating Scale and the “Parents Postoperative Pain Measure” (PPPM) questionnaire, and appetite using the visual analogue scale (VAS).

Results

Patients in the PT group and in the TT group had no demographical differences in terms of age, BMI, exposure to smoking, area of living, and attending a day care center. Comparison between PT and TT revealed a significant difference in both pain and appetite scales. Patients who underwent PT had significantly lower PPPM scores on the 1^st, 2^nd, 4^th, 5^th, 6^th, and 10^th day after surgery compared to the TT patients. Further validation was revealed by the Wong–Baker Faces Pain Rating Scale, showing that the PT surgery group experienced significantly less postoperative pain compared to the TT surgery group. Assessing the appetite using the visual analogue scale favored PT over TT. Comparisons revealed that most PT patients returned to their normal eating habits starting at day 4 while this was applicable in the TT group at day 10. Postoperative pain improved from day 1 to day 10 in both surgical groups.

Conclusion

In conclusion, the recovery process after the PT surgery causes less postoperative morbidity, thus an earlier return to normal activity compared to the TT. The patients of the latter group are affected by more pain and less appetite over the first 10 days after the surgery.

Association of Perioperative Opioid Prescriptions With Risk of Complications After Tonsillectomy in Children

Importance

Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced.

Objective

To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids.

Design, Setting, and Participants

This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children.

Main Outcomes and Measures

The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids.

Results

Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications.

Conclusions and Relevance

These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

OBJECTIVE

The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA).

STUDY DESIGN

Online survey.

METHOD

A sample of pediatric anesthesiologists received the survey by email.

RESULTS

110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05).

CONCLUSION

Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.

Children and their parents' assessment of postoperative surgical pain: Agree or disagree?

OBJECTIVE

The purpose of this study is to compare postoperative pain scores between children undergoing tonsillectomy and adenoidectomy (T&A) surgery and their parents, identify potential predictors for this disagreement, and determine possible impact on analgesic administration.

METHODS

This is a prospective longitudinal study conducted with children undergoing outpatient T&A in 4 major tertiary hospitals and their parents. Children and their parents were enrolled prior to surgery and completed baseline psychological instruments assessing parental anxiety (STAI), parental coping style (MBSS), child temperament (EAS) and parental medication administration attitude questionnaire (MAQ). Postoperatively, parents and children completed at-home pain severity ratings (Faces Pain Scale-Revised, children; Numeric Rating Scale, parents) on postoperative recovery days 1, 2, and 3, reflecting an overall pain level for the past 24 h. Parents also completed a log of analgesic administration. Based on postoperative pain scores, parent-child dyads were classified as overestimators (i.e., parents rated their child's pain higher than children rated their own pain), in agreement (i.e., rating in agreement), or underestimators (i.e., parents rated their child's pain lower than children rated their own pain).

RESULTS

A significant proportion of parent-child pairs disagreed on pain ratings on postoperative days 1-3 (30.05%-35.95%). Of those pairs in disagreement, the majority of parents overestimated their child's pain on all three postoperative days, specifically such that a total of 24-26% parents overestimated their child's pain on postoperative days 1, 2, and 3. Repeated measures ANOVA demonstrated that parents in the overestimator group administered higher, though still within safe limits, amounts of ibuprofen and oxycodone (mg/day) than did the underestimator or agreement groups. Multiple regression models showed hospital site as the only independent predictor for postoperative pain rating disagreement between children and parents.

CONCLUSIONS

Since parents overestimate their child's postoperative pain and may administer more analgesics to their child, it is essential to develop a standardized method of child pain assessment and a tailored recommended postoperative analgesic regimen amongst medical providers for children undergoing T&A.

Pain Management After Surgical Tonsillectomy: Is There a Favorable Analgesic?

The aim of this study was to examine how ibuprofen and paracetamol prevent pain after cold-steel extracapsular tonsillectomy in children. Also, we examined the relation between age, gender, nausea, postoperative bleeding, antibiotic use, type of diet, and postoperative pain intensity and the type of administered analgesic. A prospective study was conducted on 147 children (95 males and 52 females, aged 7-17 years) who underwent tonsillectomy in the Clinical-Hospital Center "Dragiša Mišović" from January 1 to June 30, 2016. The degree of pain was measured using a visual analog scale (VAS). We did not observe any significant differences in postoperative nausea, hospitalization rate postoperative bleeding, and antibiotic use between the paracetamol and ibuprofen groups. A test of within-patient effects showed that VAS scores changed significantly during the postoperative follow-up period (P = .00), but there were no significant differences between the groups (P = .778). After 12 hours, 29.3% of the patients on paracetamol and 21.8% on ibuprofen were transferred to a soft diet; after 24 hours, 84.8% of the paracetamol group and 85.5% of the ibuprofen group were on a soft diet (χ² test, P < .05). There was a statistically significant correlation between VAS scores measured 4 hours after the surgery and the time of transference to the soft diet (Spearman ρ test, P < .001). The transfer to soft and normal diets was not significantly different between the 2 groups as assessed by the VAS scores (Pearson χ² test, P = .565).There is still no consensus on the most effective postoperative pain-control regiment after tonsillectomy. This study showed that satisfactory pain management was achieved equally with both paracetamol and ibuprofen.

Postoperative Pain and 14-Day Recovery in Children Undergoing Adenotonsillectomy: Low Thermal Damage Device Versus Electrosurgery

This was a randomized controlled trial of low thermal damage device versus traditional electrosurgery in children 3 to 17 years old with a clinical diagnosis of sleep disordered breathing, obstructive sleep apnea with adenotonsillar hypertrophy, or recurrent adenotonsillitis. Pain score (Wong-Baker FACES pain scale) was recorded each morning before eating, drinking, or administering pain medication for 14 days postoperatively. Seventy-five children were enrolled. There was no difference in the rate of decrease in pain scores. A significant interaction between rate of pain decrease and number of pain medication doses was present ( P < .0001). Median number of pain medication doses was greater with electrosurgery (36, range: 7-49) versus low thermal device (21, range: 2-124; P = .001). Pain scores reached 0 after a median of 7 days (95% confidence interval [CI], 5.2-8.6) for low thermal device and 9 days (95% CI, 8.0-10.0) for electrosurgery ( P = .67). One child randomized to electrosurgery was withdrawn due to hospitalization for postoperative bleed. In children, low thermal device results in significantly less pain medication used during the postoperative period than electrosurgery.