Phenol as an adjuvant anesthetic for tympanostomy tube insertion

Use of Topical Phenol in Awake Young Children for Tympanostomy Tube Placement

Importance: Phenol kits cleared by the Food and Drug Administration (FDA) are indicated as a topical anesthetic for the tympanic membrane (TM) in adults. However, there is no existing literature that reports outcomes to support the safety and use of phenol on the TM of awake children. Objective: Determine if topical phenol is safe and at low risk for complications and therefore be used effectively in awake children to facilitate office otologic procedures as in adults. Design, Setting, and Participants: Children under 21 years of age whose parents agreed to participate in an awake office setting for tympanostomy tube (TT) placement. All children had TT placement after phenol placement on the TM prior to insertion. Main Outcomes and Measures: TM perforation or other signs of TM complications through a minimum of 6-month clinical follow-up, along with assessment of the tolerability of the procedure by the child. Results: A total of 228 children with an age range of 6 months to 15.9 years and 435 TMs completed TT placement using phenol as a local anesthetic while awake in the office. There were no complications reported in the 204 children at the first follow-up visit post TM placement within 3 to 10 weeks. Of the 93 children followed up at least 6 months, there were no TM complications reported. Conclusions: This is the first study to report the outcomes on the use of phenol in an office setting in children. In this large experience, phenol appears to be tolerable and safe for use in young children in the office and is a potential safe choice of topical anesthesia for surgeons if they choose to perform office procedures such as myringotomies or TT placement on children.

Wine, Honey, and Boiling Oil: A Modern Understanding of Ancient Wound Care Practices

The origins of wound care date back to ancient civilizations. From boiling oil to honey to wine, healers and caregivers have adopted a fascinating array of items to cleanse, dress, and bandage wounds over the ages. While wound care practices have developed over time, the physicians and surgeons of ancient times and the Middle Ages helped build the foundation for present-day wound care. A modern scientific understanding of these treatments illustrates why practitioners abandoned some practices while others remain in use today.

Use of Phenol as a Local Anaesthetic for Adult Grommet Insertion in Resource-Limited Settings: A Preliminary Report

BACKGROUND

Grommet insertion is one of the most commonly performed minor surgical procedures in otolaryngological practice. For such minor procedures in the outpatient, local anaesthetics are preferred; this is even more so in adults especially for grommet insertion. This study described our experience with the use of phenol as a local anaesthetic agent for grommet insertion in adults.

METHODS

Phenol was used as a local anaesthetic agent that was applied topically for grommet insertion in adult patients as outpatient procedures between January and September 2018 in two tertiary hospitals. Data collected were analyzed using the Statistical Package for Social Sciences (SPSS IBM) version 23.0 computer software.

RESULTS

Nineteen ear drums were operated in patients aged between 20 and 52 years. No pain or discomfort was reported by 89.5% and 94.7% had no bleeding. There was no vertigo in all the cases that completed the procedures.

CONCLUSION

This preliminary result shows that the use of phenol as a topical local anesthetic is simple, safe, and effective especially in resource-limited environments.

Do children undergoing bilateral myringotomy with placement of ventilating tubes benefit from pre-operative analgesia? A double-blinded, randomised, placebo-controlled trial

OBJECTIVE

A double-blinded, randomised, placebo-controlled trial was conducted to determine whether routine pre-operative analgesia is beneficial in reducing post-operative ear pain following bilateral myringotomy and tube placement.

METHODS

Forty-five children (aged 3-15 years) were randomised to receive either pre-operative analgesics (paracetamol and ibuprofen) (n = 21) or placebo (n = 24). All children underwent sevoflurane gas induction with intranasal fentanyl (2 mcg/kg) to reduce the incidence of emergence agitation. Post-operative pain scores were measured using the Wong-Baker Faces Pain Rating Scale. Median pain scores taken 90 minutes post-surgery, and the highest pain score recorded prior to 90 minutes, were analysed.

RESULTS

There were no statistical differences between the median pain scores at 90 minutes or subsequent need for rescue analgesia. Emergence agitation did not occur in any child. Inadvertent ear trauma, use of an intravenous cannula or airway adjunct did not affect pain scores.

CONCLUSION

Routine pre-operative analgesia does not reduce pain scores in the early post-operative period. Simple analgesics are effective for rescue analgesia in the minority of cases.

Iatrogenic phenol injury: a case report and review of medication safety and labeling practices with flexible laryngoscopy

Medication errors can be reduced by following standards in patient identification and medication labeling. We present an investigation of a life-threatening event from medication error: A newborn that received intranasal phenol instead of topical anesthetic prior to flexible laryngoscopy. The patient required urgent intubation for respiratory distress and suffered chemical burns of the face, neck, and upper aerodigestive tract. The hospital course was prolonged and included intensive care, delayed oral feeding with enteral support, and the need for several endoscopies. Current standards of medication labeling are reviewed as well as evidence for and against using topical agents for flexible laryngoscopy.

The effect of dexmedetomidine during myringotomy and pressure-equalizing tube placement in children

BACKGROUND

Bilateral myringotomy (BMT) is a commonly performed otolaryngologic procedure in children.

OBJECTIVES

To examine the effects of intranasal dexmedetomidine, an α(2)-adrenoceptor agonist, on time-averaged pain scores, pain control, need for rescue analgesia, and agitation scores in children undergoing BMT.

METHODS

We designed a trial to enroll 160 children randomized to one of four groups: two study groups, dexmedetomidine (1 or 2 μg·kg(-1)), or two control groups representing our institutional standards of practice (intranasal fentanyl-2 μg·kg(-1) or acetaminophen as needed postoperatively).

RESULTS

After 101 children were enrolled, patient caregivers observed that some enrollees were excessively sedated and required prolonged postanesthesia care unit (PACU) stay. This observation led to an unplanned interim analysis and early trial termination. After data were collected, severe nonnormality of pain and agitation scores necessitated a switch of the outcome to assess repeated measurements of the proportion of patients with pain, severe pain, and agitation. Demographics, time to emergence, and agitation were similar among all groups. The risk of requiring acetaminophen rescue (P < 0.0001) and proportion of patients having pain (P = 0.016) was significantly higher in one control group (rescue analgesia only) compared with fentanyl or dexmedetomidine groups. Importantly, length of stay in the PACU was significantly longer in dexmedetomidine-2 μg·kg(-1)-treated compared with dexmedetomidine-1 μg·kg(-1)-treated, fentanyl-treated, or the control group, P = 0.0037.

CONCLUSIONS

In this trial, we were unable to answer the original question as to the role of dexmedetomidine on time-averaged pain and agitation scores after BMT. However, our findings clearly demonstrate that in children undergoing BMT, at higher doses, dexmedetomidine significantly prolongs length of stay in the PACU.

Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery

OBJECTIVES

The objective of this study was to determine whether the incidence of emergence agitation (EA) can be reduced by adding an additional, faster onset, non-IV analgesic, intranasal fentanyl or intramuscular (im) ketorolac to rectal acetaminophen.

AIM

To compare the incidence of EA after analgesia with two agents vs acetaminophen alone in pediatric patients after bilateral myringotomy procedures (BM&T).

BACKGROUND

Anesthesia for BM&T is usually performed with volatile anesthetics as a single agent without securing intravenous access. The anesthetic agent most commonly used is sevoflurane; however, EA has been reported in up to 67% of patients. Emergence agitation is distressing for parents, can impair the ability of nursing staff to adequately monitor the child, and can result in a child injuring him/herself if it is severe.

METHODS/MATERIALS

A standardized anesthetic was used with oral midazolam premedication and sevoflurane for induction, and maintenance of anesthesia. All patients received 40 mg·kg(-1) rectal acetaminophen, group 1 received acetaminophen alone, group 2 received acetaminophen and 1 mcg·kg(-1) of intranasal fentanyl, and group 3 received acetaminophen and 1 mg·kg(-1) of intramuscular ketorolac. Incidence of EA was compared using chi-square test between the acetaminophen group alone vs the two-agent analgesia groups combined.

RESULTS

  There were no differences in demographic and clinical characteristics between the two groups. There were no statistically significant differences between the three groups for the incidence of EA at any time point during recovery from anesthesia nor were there any significant differences in pain scores or side effects. No significant side effects because of the administration of a second analgesic agent were reported.

CONCLUSIONS

We conclude that two-agent analgesia is not superior to acetaminophen alone for decreasing the incidence of EA after inhalation anesthesia with sevoflurane for BM&T surgery. Our overall incidence of EA was low compared to previous studies, which could potentially have decreased our ability to detect differences between groups.

Diclofenac or paracetamol for analgesia in paediatric myringotomy outpatients

This prospective, randomized, double-blind study compared the analgesic efficacy of oral diclofenac resinate 0.5 mg.kg(-1) with paracetamol 15 mg/kg(-1) for control of postoperative pain in paediatric patients for outpatient bilateral myringotomy and tube insertion. Paracetamol, the most commonly used oral analgesic for paediatric patients, was compared with a new palatable syrup formulation of diclofenac. Sixty-three ASA 1 orA SA 2 children aged one year and above were randomly assigned to receive diclofenac (Group A) or paracetamol (Group B). The study drug was given 30 to 60 minutes before induction of anaesthesia. Anaesthesia was induced with either inhalational sevoflurane or intravenous thiopentone. All subjects received intravenous fentanyl 1 microg/kg(-1) intraoperatively. Postoperative pain was assessed by a blinded observer using the CHEOPS score on eye-opening, and then at 10, 30 and 60 minutes. Children with a CHEOPS score > 7 received further fentanyl 1 microg x kg(-1). The number of cases requiring this "rescue" analgesia was recorded. Both groups were comparable in demographics, induction technique, duration of anaesthesia and time between premedication and induction of anaesthesia. Overall, CHEOPS scores were low for both groups at all times and did not differ between the groups at any time. Twenty per cent of the diclofenac group and 27% of the paracetamol group required rescue analgesia (not statistically significant). The efficacy of diclofenac 0.5 mg x kg(-1) and paracetamol 15 mg x kg(-1) as oral analgesic premedication for BMT was comparable in children receiving an anaesthetic which included intraoperative administration of fentanyl 1 microg x kg(-1).

The effect of intranasal fentanyl on the emergence characteristics after sevoflurane anesthesia in children undergoing surgery for bilateral myringotomy tube placement

Children undergoing placement of bilateral myringotomy tubes (BMT) often exhibit pain-related behavior (agitation) in the postanesthesia care unit. We compared the emergence and recovery profiles of pediatric patients who received sevoflurane with or without supplementary intranasal fentanyl for BMT surgery. By using a prospective, double-blinded design, 150 children 6 mo to 5 yr of age, scheduled for routine BMT surgery, were anesthetized with sevoflurane (2%-3%) in a 60% N(2)O/O(2) gas mixture. Patients were randomized to receive equal volumes of intranasal saline (Control), 1 microg/kg fentanyl or 2 microg/kg fentanyl. A blinded observer evaluated each patient using a previously described 4-point agitation scale and the Steward recovery scale. Response to parental presence was observed after a score of six (full recovery) was achieved on the Steward recovery scale. There were no significant differences among the three groups regarding age, weight, surgeon, duration of anesthesia, or ear condition. Recovery times and emergence characteristic scores were not statistically different. Agitation scores were significantly reduced in the 2-microg/kg Fentanyl group as compared with the Control group (P = 0.012). Fentanyl 2 microg/kg is recommended to reduce the incidence of agitation seen in these patients.

IMPLICATIONS

We examined the use of nasally administered fentanyl for the relief of agitation or discomfort after placement of bilateral myringotomy tubes in 150 children ages 6 mo to 5 yr using a prospective, double-blinded design. Fentanyl 2 microg/kg was found to reduce the incidence of agitation in these patients.

Analgesia after bilateral myringotomy and placement of pressure equalization tubes in children: acetaminophen versus acetaminophen with codeine

Despite the brief nature of the procedure with limited tissue trauma, some form of analgesia is required in most children after bilateral myringotomy and placement of pressure equalization (PE) tubes. Previous studies have demonstrated the relative inefficacy of acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs), with 30%-55% of patients requiring supplemental postoperative analgesia. We undertook a prospective study evaluating the efficacy of the preoperative administration of oral acetaminophen (15 mg/kg) versus acetaminophen (10 mg/kg) and codeine (1 mg/kg). Fifty ASA grade I or II patients were randomized to receive oral midazolam premedication (0.7 mg/kg) mixed in either acetaminophen or acetaminophen with codeine elixir. Anesthesia was induced and maintained with halothane in nitrous oxide and oxygen. Postoperative pain was assessed at four times during the postoperative course using an objective pain scale. The two groups were similar with respect to age, weight, gender, duration of anesthesia, and duration of the surgical procedure. The patients who received acetaminophen with codeine had lower pain scores at all four points when compared with patients who received acetaminophen. None of the 25 patients who received acetaminophen with codeine required supplemental analgesics compared with 12 of 25 who received acetaminophen. No adverse effects were noted in either group. We conclude that the preoperative administration of acetaminophen with codeine provides superior analgesia after bilateral myringotomy and placement of PE tubes.

Perioperative effects of oral ketorolac and acetaminophen in children undergoing bilateral myringotomy

Prophylactic administration of analgesics before surgery can decrease the intraoperative anaesthetic requirement and decrease pain during the early postoperative period. In a double-blind, placebo-controlled study involving 90 healthy ASA physical status I or II children undergoing bilateral myringotomy, we compared the postoperative analgesic effects of oral acetaminophen and ketorolac, when administered 30 min before induction of anaesthesia. Patients were randomized to receive saline (0.1 ml.kg-1), acetaminophen (10 mg.kg-1) or ketorolac (1 mg.kg-1) diluted in cherry syrup to a total volume of 5 ml. Anaesthesia was induced and maintained with halothane and nitrous oxide via a face mask. Postoperative pain was assessed by a blinded observer using an objective pain scale. The three study groups were similar with respect to demographic data, duration of anaesthesia and surgery, induction behaviour, oxygen saturation, incidence of postoperative emesis and, recovery times. The ketorolac group had lower postoperative pain scores and required less frequent analgesic therapy in the early postoperative period compared with the acetaminophen and placebo groups. In contrast, there were no differences in pain scores or analgesic requirements between the acetaminophen and the placebo groups. We conclude that the preoperative administration of oral ketorolac, but not acetaminophen, provided better postoperative pain control than placebo in children undergoing bilateral myringotomy.