Postoperative Pain in Adult Tonsillectomy: Is There Any Difference Between the Technique?

Glossopharyngeal Nerve Block for the Management of Post-Tonsillectomy Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To assess the effectiveness of glossopharyngeal nerve block (GNB) in the treatment of postoperative pain among patients undergoing tonsillectomy, a systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. Various databases, including PubMed, Cochrane, Scopus, Web of Science, and Google Scholar, were systematically screened from inception until March 2023. The included studies were assessed using the RoB-2 tool. The outcomes of interest included reporting on at least one of the predetermined efficacy and safety endpoints, such as postoperative pain, the severity of swallowing, and the incidence of postoperative complications such as bleeding, nausea and vomiting, hoarseness, nasal obstruction, dyspnea, foreign body sensation, and dry mouth. Dichotomous data were collected as risk ratios (RR), and continuous data were collected as standardized mean differences (SMD). The overall analyses were conducted using a random-effects model. In total, 492 participants were enrolled in our investigation, with 245 and 247 participants allocated to the GNB and control arms, respectively. When comparing postoperative pain levels during rest and swallowing, the GNB arm showed a significantly reduced effect size compared to the control arm (n = 5 RCTs, SMD= -1.38, 95% CI [-1.82, -0.94], p < 0.001; n = 4 RCTs, SMD= -1.43, 95% CI [-2.15, -0.72], p < 0.001), respectively. Overall, there was no substantial variation in effect size between the GNB and control arms with regard to the severity of difficulty in swallowing (p = 0.7). Additionally, there were no significant differences observed between the GNB and control groups in terms of postoperative complications endpoints (p > 0.05). This thorough analysis showed that GNB had both statistical and clinical advantages for patients after a tonsillectomy. It was found that GNB was an effective, safe, and straightforward method for managing early postoperative pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04928-w.

Assessing the efficacy of celecoxib after tonsillectomy and/or adenoidectomy: A systematic review and meta-analysis of randomised control trials

OBJECTIVES

Tonsillectomy and adenoidectomy are common surgical procedures that cause persistent pain, bleeding, and functional limitations. We aimed to investigate the efficacy of celecoxib compared with a placebo for managing post-tonsillectomy or adenoidectomy pain and other adverse events.

DESIGN

Systematic review and meta-analysis.

METHODS

We conducted a systematic literature search in the PubMed, Cochrane, and Google Scholar databases from inception until July 2023. Dichotomous outcomes have been reported as risk ratios (RR) while continuous outcomes were reported using mean differences (MD). A funnel plot was drawn to investigate publication bias.

RESULTS

From 1394 records identified, 6 randomised double-blind trials comprising 591 participants undergoing tonsillectomy and/or adenoidectomy were eligible for inclusion. A high dose (400 mg) of celecoxib was effective in decreasing the pain score for 'worst pain' after the procedure (MD: -10.98, [95% CI: -11.53, -10.42], p < .01, I2 = 0%) while a low dose (200 mg) was not significantly effective (p = 0.31). For managing other outcomes such as vomiting (RR: 1.37 [95% CI: 0.69, 2.68], p = 0.37, I2 = 67%), diarrhoea (RR: 1.41, [95% CI: 0.75, 2.64], p = .29, I2 = 42%), dizziness/drowsiness (RR: 0.90, [95% CI: 0.71, 1.15], p = .48, I2 = 0%), functional recovery time (p = .74), and headache (p = .91), there was no significant difference between the group on celecoxib and the placebo group regardless of dosage. Finally, there was no significant difference (RR: 1.02, [95% CI: 0.91, 1.15], p = .69, I2 = 0%) in the effect of the intervention on minimum bleeding, moderate bleeding, and profuse bleeding.

CONCLUSION

This meta-analysis provides robust evidence pooled from high-quality trials and raises questions about the efficacy of celecoxib for tonsillectomy and/or adenoidectomy, challenging existing perceptions.

Posttonsillectomy Pain Relief and Wound Healing by Applying Bismuth Iodoform Paraffin Paste (BIPP) to Dissected Tonsillar Beds

Introduction  Tonsillectomy is one of the most common operations performed by otorhinolaryngology surgeons worldwide; however, the insufficient quality of the postoperative pain management and effective posttonsillectomy pain relief remain a clinical dilemma. Objective  To evaluate the efficacy of applying bismuth iodine paraffin paste (BIPP) to the dissected fossa as an adjuvant therapy for a better outcome in terms of posttonsillectomy pain management and due to its wound healing properties. Methods  The present is a prospective randomized control pilot study with 44 patients aged > 7 years who underwent tonsillectomy. The patients were divided into two groups: the control group and the group that had BIPP applied to the dissected tonsillar fossa. The visual analogue scale score and the post-onsillectomy percentage of tonsillar fossa epithelization were recorded and evaluated. Results  Both subjectively and objectively, there a was statistically significant pain-relieving effect in the BIPP group within the first 5 postoperative days ( p  < 0.05). From postoperative day 3 onward, the dissected area of the tonsillar fossa healed significantly faster in the BIPP group compared with the control group, and it became stable on day 14. Conclusion  The topical application of BIPP showed a better pain-relieving effect, it was safe, and hastened wound healing after tonsillectomy.

Patient Satisfaction with Nonopioid Postoperative Analgesia in Head and Neck Surgery: A Prospective Randomized Trial

OBJECTIVE

To evaluate patients' satisfaction with opioid versus opioid-sparing postoperative analgesia in patients undergoing outpatient head and neck surgery.

STUDY DESIGN

Prospective randomized trial.

SETTING

Tertiary care academic hospital.

METHODS

Adult patients undergoing outpatient head and neck surgery were randomly assigned to 1 of 3 analgesic regimens. First- and second-line medications were the following by group (1) Hydrocodone-acetaminophen with ibuprofen, (2) ibuprofen with hydrocodone-acetaminophen, and (3) ibuprofen with acetaminophen. Preoperative counseling was provided to patients regarding expected pain and proper medication use. Postoperative questionnaires were administered to assess satisfaction.

RESULTS

One hundred three patients were enrolled in the study (mean age, 56.5 years; women, 75 [73%]). The mean satisfaction score with the pain regimen assigned was similar between the 3 groups (scale 0-10, [7.7, 8.3, 8.5, P = .46]). A similar percentage of patients in each group reported that surgery was more painful than anticipated (25%, 32%, 26%, P = .978), and a similar percentage of patients reported willingness to utilize the same analgesic regimen following future surgeries (75%, 83%, 76%, P = .682). Additional questions evaluating the side effect profile, maximum and minimum pain scores, and difficulty of recovery were not statistically different between the 3 groups.

CONCLUSION

In the postoperative population for outpatient head and neck surgeries, there was no significant difference in patient satisfaction and pain control between the opioid and nonopioid arms. Providers should discuss opioid-sparing regimens preoperatively with patients and describe them as effective in providing adequate pain control without a significant impact on patient's perception of care.

Postoperative Morbidity of Different Tonsillectomy Techniques: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare different tonsillectomy techniques in terms of postoperative bleeding incidence and postoperative pain.

METHODS

An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were postoperative bleeding incidence and mean postoperative pain score.

RESULTS

A total of 6464 patients were included for five different interventions (cold dissection tonsillectomy; extracapsular coblation tonsillectomy; intracapsular coblation tonsillectomy [ICT]; bipolar diathermy tonsillectomy [BDT]; monopolar diathermy tonsillectomy). ICT showed the lowest absolute risk (4.44%) of postoperative bleeding incidence (73.31% chance of ranking first) and the lowest mean postoperative pain score (1.74 ± 0.68) with a 94.0% chance of ranking first, whereas BDT showed both the highest absolute risk of bleeding incidence (10.75%) and the highest mean postoperative pain score (5.67 ± 1.43).

CONCLUSIONS

ICT seems to offer better postoperative outcomes, in terms of reduced risk of bleeding and reduced pain. Further prospective studies are advised to confirm these findings.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1696-1704, 2024.

A comparison of coblation and modified monopolar tonsillectomy in adults

OBJECTIVE

To compare the intraoperative records and postoperative clinical outcomes of adults who underwent coblation and modified monopolar tonsillectomy tonsillectomies.

MATERIALS AND METHODS

Adult patients with tonsillectomy were randomly divided into the coblation and modified monopolar tonsillectomy groups. The estimated blood loss, postoperative pain score, operation time, post-tonsillectomy hemorrhage (PTH), and cost of disposable equipment were compared.

RESULTS

Pain intensity in the coblation and monopolar groups was similar on postoperative days 3 and 7. However, the mean maximum pain score in the monopolar group was significantly higher compared to the coblation group on postoperative days 1 (P < 0.01) and 2 (P < 0.05).Secondary PTH occurred in 7.1% (23/326) of patients in the coblation group and 2.8% (9/327) of patients in the monopolar group (P < 0.05).

CONCLUSION

Although pain was significantly increased on postoperative days 1 and 2 in the modified monopolar tonsillectomy group, the operation time, secondary PTH, and medical costs were significantly decreased compared to the coblation technique group.

Implication of American Society of Anesthesiologists Physical Status (ASA-PS) on tonsillectomy with or without adenoidectomy outcomes

BACKGROUND

The American Society of Anesthesiologists Physical status classification (ASA-PS) is a simple categorization of a patient's physiological status during the perioperative period. The role of ASA-PS in predicting operative risk and complications following tonsillectomy with or without adenoidectomy (T ± A) has not been studied. The objective of the study was to identify the association of the pre-operative ASA-PS with 30-day complication rates and adverse events following T ± A.

STUDY DESIGN

A retrospective analysis was performed using data from the American College of Surgeons' National Surgical Quality Improvement Program database (ACS NSQIP) of patients aged 16 years or older who underwent T ± A between 2005 and 2016. Patients were stratified into ASA-PS Classes I/II and III/IV. Patient demographics, preoperative comorbidities, pre-operative laboratory values, operation-specific variables, and postoperative outcomes in the 30-day period following surgery were compared between the two subsets of ASA-PS groups.

RESULTS

On multivariate analysis, patients with ASA class III and IV were more likely to experience an unplanned readmission (OR 1.39, 95 % CI 1.09-1.76; p = 0.007), overall complications (OR 1.49, 95 % CI 1.28-1.72; p < 0.001), major complications (OR 1.52, 95 % CI 1.31-1.77, p ≤ 0.001), reoperation (OR 1.33, 95 % CI 1.04-1.69; p = 0.022), and extended length of stay >1 day (OR 1.78, 95 % CI 1.41-2.25; p < 0.001) following a T ± A.

CONCLUSION

Higher ASA-PS classification is an independent predictor of complications following T ± A. Surgeons should aim to optimize the systemic medical conditions of ASA-PS classes III and IV patients prior to T ± A and implement post-operative management protocols specific to these patients to decrease morbidity, complications, and overall health care cost.

Associations Between Post-tonsillectomy Hemorrhage and Anatomical Subsites of the Tonsillar Fossa

OBJECTIVE

This study presents a novel classification of the anatomical subsites of the tonsillar fossa and discusses their associations with post-tonsillectomy hemorrhage (PTH) after extracapsular tonsillectomy.

MATERIALS AND METHODS

Coblation tonsillectomy was performed on three adult cadavers and the anatomical subsites of the tonsillar fossa based on the distribution of the tonsillar feeding artery: the upper pole (subsite A), most of the tonsil body (subsite B), the inferior tonsil body (subsite C), and components of the lower pole (subsites D and E). Extracapsular tonsillectomy was prospectively performed using various surgical techniques and PTH was evaluated.

RESULTS

A cadaveric study revealed that the intra- and extra-capsular vessel topographies were essentially identical. Although the demarcation lines varied either up or down by a few millimeters, the arterial vascular network was particularly dense at subsites D and E, and the vessel diameter at these subsites was significantly greater than at subsite C and also (especially) at subsite E. Of 680 patients who underwent tonsillectomy, PTH developed early in 13 (31.7%) and late in 28 (68.3%). Surgical interventions were required by 29/41 patients (70.7%). Subsites D and E were the most common subsites of late PTH and PTH that required intervention. Such intervention was rarely necessary when PTH developed at subsite A or B.

CONCLUSIONS

The new classification of the anatomical subsites of the tonsillar fossa aids inexperienced surgeons and provides an anatomical rationale for variation in surgical technique that minimizes vascular injury, thus improving safety.

The analgesic and anti-haemorrhagic efficacy of platelet-rich plasma in tonsillectomy: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

To evaluate the analgesic and anti-haemorrhagic efficacy of platelet-rich plasma (PRP) among patients undergoing tonsillectomy.

DESIGN

A systematic review and meta-analysis of randomised controlled trials (RCTs).

SETTING

PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases were screened from inception until July 2021, and updated in December 2021.

PARTICIPANTS

Patients undergoing tonsillectomy.

MAIN OUTCOME MEASURES

The efficacy endpoints of postoperative pain and haemorrhage were summarised as standardised mean difference (SMD) and risk ratio (RR), respectively, with 95% confidence interval (CI).

RESULTS

Seven RCTs Seven RCTs were analysed, comprising a total of 392 patients. Risk of bias evaluation showed an overall high risk in one RCT, low risk in four RCTs and some concerns in two RCTs. The pooled results revealed that the mean postoperative pain score was significantly reduced in favour of the PRP group compared with the control group (SMD = -1.38, 95% CI [-1.91, -0.85], p < 0.001). Subgroup analysis showed the effect estimate was statistically significant for early postoperative pain (Day 0 to Day 3), without substantial difference between both groups on late postoperative pain (Days 5 and 7). Moreover, the rate of postoperative haemorrhage was significantly reduced in favour of the PRP group compared with the control group (RR = 0.16, 95% CI [0.05, 0.50], p = 0.001). Subgroup analysis showed the effect estimate was statistically significant for the rate of primary and secondary haemorrhage.

CONCLUSION

PRP was associated with significant reduction in postoperative pain and haemorrhage among patients undergoing tonsillectomy.

[Analysis of risk factors for re-operation due to postoperative haemorrhage following coblation-assisted tonsillectomy]

Objective:To investigate the risk factors for re-operation due to postoperative haemorrhage following coblation-assisted tonsillectomy. Methods:The clinical data of 135 patients with haemorrhage after coblation-assisted tonsillectomy in our hospital from January 2015 to May 2022 were collected, According to the patients received reoperation after tonsillectomy or not, all patients were divided into the reoperation group （n=43） and non-reoperation group （n=92）,clinical data were compared between the two groups. Results:Univariate analysis showed that there was no significant difference in gender, age, postoperative intravenous glucocorticoid use, diabetes and hypertension between the two groups（P>0.05）, Univariate and multivariate factor analyses showed that early haemorrhage, obvious hemorrhage points were independent risk factors for re-operation due to postoperative haemorrhage（P<0.05）. Conclusion:Early haemorrhage and obvious hemorrhage points are independent risk factors for re-operation due to postoperative haemorrhage following coblation-assisted tonsillectomy.

A prospective, randomized, single-blind study comparing coblation and monopolar extracapsular tonsillectomy

Objective

The aim of this study was to compare intraoperative blood loss, postoperative pain, post-tonsillectomy hemorrhage (PTH), and medical costs associated with extracapsular tonsillectomy between coblation and monopolar electrocautery in children.

Materials and methods

This study included 293 patients aged 6-15 years planned to undergo extracapsular tonsillectomy. Data on estimated blood loss, postoperative pain score, operation time, PTH, and the cost of disposable equipment were collected.

Results

Coblation extracapsular tonsillectomy was associated with significantly lower mean pain scores than monopolar technique on postoperative days 1 (p <.001) and 2 (p = 0.02). However, the pain score was similar between the groups at all other time points. The monopolar group had a significantly shorter operation time compared to the coblation group (11.09 ± 7.53 vs. 17.12 ± 4.29 min, p <.001). Intraoperative estimated blood loss was not significantly different between the groups (p = .43).The cost of extracapsular tonsillectomy was significantly lower in the monopolar compared to the coblation group (US$ 28.18 vs. US$ 430.48, p <.001). PTH occurred in 17 patients (5.80%) and required a second surgery. Secondary PTH occurred in 6.16% (9/146) and 0.68% (1/147) of patients in the coblation and monopolar groups, respectively (p <.001). The PTH was significantly higher in the tonsillitis compared to in the tonsillar hypertrophy (12.37% vs. 2.55%, p = .002), However, the difference of PTH was not significant among mean pain scores subgroups. Of the 17 patients with PTH, the lower pole, middle portion, and upper pole were involved in 15 (88.24%), 2 (11.76%), and 0 cases, respectively.

Conclusions

Coblation and novel monopolar electrocautery extracapsular tonsillectomy are associated with similar postoperative pain scores except on postoperative days 1 and 2. However, monopolar technique offers significant advantages over coblation method with less operative time, decreased secondary PTH, and cost.Level of Evidence: NA.

Opioid Usage and Pain Control in Benign Oropharyngeal Surgery: An Observational Prospective Study

OBJECTIVES

Little data is available on opioid usage in the adult population for benign oropharyngeal surgery. The objective here is to evaluate opioid prescribing patterns, opioid consumption, and patient pain patterns following benign oropharyngeal surgery, specifically tonsillectomy and adenoidectomy, tonsillectomy alone, and expansion sphincter pharyngoplasty.

METHODS

Patients aged ≥18 years old and received a tonsillectomy, tonsillectomy and adenoidectomy, or expansion sphincter pharyngoplasty between November 2019 and August 2020 were included. Patients were provided a survey which included a visual analog scale for recording their pain postoperatively and the amount of opioid they had remaining.

RESULTS

About 103 patients completed the post-operative questionnaire. Patients were prescribed 38 837 morphine milligram equivalents and used 28 644: approximately 26% went unused, which is the equivalent of 1346 5 mg oxycodone pills. Opioid consumption correlated with the initial dosage: patients consumed 12% more narcotic on average as the initial prescription went upwards by 50 morphine milligram equivalents. Obstructive sleep apnea, history of smoking, and being female predicted increased opioid usage in this cohort. Pain was reported the highest on postoperative day 1. A prescription of approximately 225 morphine milligram equivalents (150 mg oxycodone) was associated with decreased opioid use in this cohort. Larger initial prescriptions did not result in fewer requests for refills.

CONCLUSION

A significant amount of opioid medication went unused in this study. A prescription of 225 morphine milligram equivalents (or 150 mg oxycodone) provided appropriate analgesia for the majority of patients. Larger prescriptions may result in increased opioid consumption and may not reduce the amount of refills. More study is needed to confirm these findings.

To evaluate the role of Feracrylum (1%) as hemostatic agent in Tonsillectomy

Tonsillectomy is a common procedure performed globally. It is associated with morbidities like hemorrhage and pain. Various methods are employed to reduce them. The present study is aimed to evaluate the role of Feracrylum (1%) in traditional cold steel tonsillectomy and to measure the outcomes in terms of intra-operative bleed, intra-operative time and post operative pain and recovery. A prospective study was conducted in Department of ENT, ESI Medical College, Kalburgi Karnataka, India, for a period of two years between January 2019 to December 2020 In this study, a total of 60 patients were involved and divided them into two groups after fulfilling the inclusion and exclusion criteria. Thirty patients each undergoing tonsillectomy with the use of Feracrylum considered as Group I and without the use of Feracrylum in the tonsillar fossae considered as Group II. The study has been approved by Ethics committee and informed consent was obtained from all the study subjects. The amount of blood loss is calculated. Post operative pain based on VAS (Visual Analogue Scale) is assessed in both the groups. Assessment of recovery in days is estimated in both groups by reduced pain, gaining normal activity and normal food intake. In this study, intra-operative time in group I was 19.83 ± 3.93 min and in group II 27.16 ± 3.35 min (P < 0.001). The intra-operative blood loss in group I was 26.67 ± 4.81 ml and in group II 44.70 ± 7.59 ml (P < 0.001). Patients recovered from pain, resumed normal activity and food intake within 2-3 days in Group I and in contrast it took about 3-5 days on an average in group II. In this study, majority of the patients experienced mild pain in Group I when Feracrylum was used during hemostasis. In our study, the time taken by the patients to recover from pain, resume their normal activity and also with regard to normal food intake was rapid. On an average of 2-3 days was seen in Group I. Group II patients required 3-5 days to recover from pain and resuming normal activity and food intake. The P value of < 0.001 was highly significant. Our study has stressed that use of Feracrylum in cold steel tonsillectomy is relatively safe. Its use is associated with a significant decrease in surgical time and blood loss. Rapid recovery makes it favourable to be used in cold steel tonsillectomy.

Tonsillectomy Outcomes for Coblation Versus Bipolar Diathermy Techniques in Adult Patients: A Systematic Review and Meta-Analysis

INTRODUCTION AND AIMS

There is no consensus on the optimal tonsillectomy technique in adult patients. The study aims to identify all studies comparing the outcomes of coblation versus bipolar diathermy in adult patients undergoing tonsillectomy.

METHODS

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary outcomes were hemorrhage and postoperative pain. Secondary outcome measures included return to theatre, analgesia, intraoperative bleeding, diet, tonsillar healing, and operation time. Fixed-effects modeling was used for the analysis.

RESULTS

Six studies were identified enrolling a total of 1824 patients. There were no significant differences in terms of reactionary hemorrhage (OR = 1.81, P = .51), delayed hemorrhage (OR = 0.72, P = .20), or postoperative pain (mean difference = -0.15, P = .45); however, there is a general trend favuring coblation. For secondary outcomes, no significant differences noted in terms of intraoperative bleeding, diet, and cases returning to theatre. Analgesia administration was either insignificant or higher in the coblation group. The coblation group had longer operation time and greater healing effect on tonsillar tissue.

CONCLUSIONS

There were no significant differences in outcomes for coblation and bipolar diathermy for adult tonsillectomy patients in this systematic review and meta-analysis.

Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes

OBJECTIVE

To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation.

STUDY DESIGN

Randomized double-blinded clinical trial based on prospective parallel design.

SETTING

Academic medical center and tertiary children's hospital between March 2018 and July 2019.

METHODS

Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events.

RESULTS

Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13).

CONCLUSIONS

As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

Plasma Ablation vs Other Hot Techniques for Tonsillectomy: A Meta-analysis

OBJECTIVE

To evaluate whether plasma ablation tonsillectomy is superior to other hot techniques in reducing postoperative morbidity.

DATA SOURCES

The databases of PubMed, EMBASE, and Web of Science were used to search the literature, from inception to January 2, 2020. Randomized controlled trials (RCTs) that compared plasma ablation tonsillectomy with any other hot techniques were eligible.

REVIEW METHODS

A modified Cochrane tool was used to assess the risk of bias. The standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effects of postoperative pain, and the risk ratio (RR) was used for postoperative bleeding. Subgroup analysis was prespecified to explore the source of heterogeneity. The evidence quality of each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 15 RCTs were included (n = 1293). Comparing with other hot techniques, plasma ablation tonsillectomy may cause less pain on postoperative day 7 (SMD, -0.53; 95% CI, -0.84 to -0.23). However, the magnitude of the difference may be clinically meaningless. There were no significant differences not only in terms of postoperative pain on day 1 and day 3 but also in the incidence of postoperative bleeding, reoperation hemostasis, and return to normal diet and activities between the 2 groups.

CONCLUSION

There is still substantial uncertainty on postoperative pain, bleeding, and recovery. The current evidence is insufficient to demonstrate that plasma ablation is superior to other hot techniques for tonsillectomy.

Coblation tonsillectomy versus cold steel dissection tonsillectomy: a morphological study

Objective

To compare the extent of tissue damage produced by conventional cold steel and coblation tonsillectomy.

Methods

Twenty patients underwent conventional and 18 underwent coblation tonsillectomy. The removed tonsils were histopathologically evaluated.

Results

Analgesic use was lower in the coblation group during the early post-operative period. Histological investigation of tonsils removed by the conventional method showed intensive haemorrhage and hyperaemia in the tonsillar capsules, which was not seen in the coblation group. Furthermore, in the coblation group, there was less mast cell degranulation (p = 0.0081) and a smaller amount of skeletal muscle tissue (p = 0.0043) in the tonsillar capsules, indicating less tissue damage.

Conclusion

Compared to the cold steel technique, coblation tonsillectomy is superior in terms of less early post-operative pain and less damage to surrounding tissues. Significantly lower mast cell degranulation in coblation tonsillectomy may contribute to the reduction of post-operative pain.

Postoperative Opioid Prescribing and Consumption Patterns after Tonsillectomy

Objectives

Despite increased concern with the opioid epidemic, literature remains scant regarding narcotic prescription and use following tonsillectomy.

Study Design

Retrospective cohort study with telephone interview.

Subject and Methods

A chart review from January to August 2018 evaluated the difference between prescribed amounts of narcotic and patient-reported usage following tonsillectomy ( Current Procedural Terminology codes 42821 and 42826). Patients were excluded if they used opioids for chronic pain, had a history of chronic opioid use or substance abuse, or underwent tonsillectomy to exclude malignancy. A telephone interview assessed opioid and nonopioid usage and pain control postoperatively, including amount and form of narcotics remaining.

Results

Sixty-four patients were enrolled at a mean 4.47 months after tonsillectomy. The mean ± SD prescribed morphine milligram equivalent (MME) was 456.1 ± 281.7, with only 302.8 ± 206.2 consumed. The mean MME prescribed per day was 74.1 ± 44.8, and average days of narcotic usage postoperatively was 9.6 ± 4.6, correlating with a mean MME per day of 49.2 ± 34.3 if the maximum prescribed dose per day was consumed. Fifty-four (84.4%) patients reported pain as well controlled. Forty-three (67.2%) patients reported residual narcotic medication, with 228.1 ± 208.5 MMEs remaining per patient. Narcotic solutions were more completely consumed than tablet forms, with 23.1% and 44.0% remaining, respectively. Patients cited uncertainty about safe disposal and safeguarding for future use as reasons for keeping residual narcotic.

Conclusions

Patient-reported narcotic use is significantly lower than the amount prescribed after tonsillectomy for benign disease. Providers can use these data to adjust narcotic-prescribing patterns while maintaining appropriate pain management for patients undergoing tonsillectomy.