Natural course of tonsillectomy pain: A prospective patient cohort study

Association Between Perioperative Celecoxib, Acetaminophen, and Opioid Consumption After Palate Surgery for Obstructive Sleep Apnea

OBJECTIVE

To examine the effect of perioperative celecoxib and acetaminophen administration on opioid consumption in the first 24 hours after palate surgery for obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic center.

METHODS

Adults with OSA undergoing soft palate surgery and admitted to the hospital postoperatively between July 2013 and June 2023 were included. Study participants were also included if they underwent concurrent nasal surgery but excluded if they underwent any pharyngeal surgery other than tonsillectomy or were taking opioids prior to surgery. Opioids administered after surgery were converted to morphine milligram equivalents (MME). Multiple linear regression was used to examine the association between total MME consumed in the first 24 hours postoperatively and celecoxib and acetaminophen usage.

RESULTS

A total of 210 study participants (15.7% female) were included with a mean age of 48.8 ± 37.5 years. The mean MME consumed in the first 24 hours after palate surgery was 80.2 ± 63.9. One hundred and twenty-six (60%) study participants received perioperative celecoxib, while 195 (93%) received perioperative acetaminophen. Celecoxib use was associated with lesser MME (-2.7 ± 1.1 MME per 100 mg; P = .018) consumed postoperatively, while acetaminophen was not (-0.3 ± 0.3 MME per 100 mg; P = .43). Female gender, Asian race, and African American race were also associated with lesser MME consumed postoperatively, while autoimmune/immunosuppressive conditions and tonsillectomy were associated with greater MME consumption.

CONCLUSION

Perioperative celecoxib was associated with reduced MME consumption in the first 24 hours after palate surgery. No association was found between acetaminophen and postoperative opioid use.

Ultrasound-guided distal glossopharyngeal nerve block for post-tonsillectomy pain relief in adults: a prospective randomized study

BACKGROUND

We aimed to evaluate the safety and efficacy of the novel distal approach of ultrasound (US)-guided glossopharyngeal nerve (GPN) block at the pharyngeal wall for enhancing the quality of analgesia in patients undergoing tonsillectomy.

METHODS

Fifty patients, both male and female, between the ages of 21 and 65, categorized as ASA I-II by the American Society of Anesthesiologists (ASA) and who were scheduled for tonsillectomy, were enrolled in the study. Patients were randomly assigned to receive general anesthesia with either bilateral US-guided distal GPN block (GPN group) or no block (control group). The time for first request of analgesics, postoperative pain scores, the total amount of rescue analgesic medication consumed within a 24-hour period, and the occurrence of any adverse events were all noted.

RESULTS

The onset of first analgesic request was significantly prolonged in GPN group than the control group (P=0.013). Pain scores at 30 min, two and six hours postoperative were found to be significantly lower in GPN group than the control group both at rest (adjusted P=0.005, 0.000, and 0.020 respectively) and during swallowing (adjusted P=0.002, 0.000, and 0.015 respectively), with significantly less morphine consumption at 24 hours postoperative in GPN group compared with the control group (P=0.002). No significant postoperative block-related complications were observed.

CONCLUSIONS

In patients having tonsillectomy, pre-emptive application of US-guided distal GPN block at the pharyngeal wall enhanced the quality of analgesia and decreased the need for rescue analgesics with no major adverse effects.

A novel classification and grading scale of palatine tonsil anatomy in children

PURPOSE

The influence of tonsil anatomical differences on post-tonsillectomy hemorrhage and pain has not been studied yet. This study aimed to establish a classification and grading scale of palatine tonsil anatomy, not size, for personalized post-tonsillectomy care.

METHODS

Between August 2020 and August 2021, 337 children who underwent extracapsular tonsillectomy were recruited. The images of tonsil anatomy during the surgery were recorded and then classified and graded. Postoperative hemorrhage was recorded, and the degree of pain was measured using a visual analog scale (VAS). The primary outcomes were the associations between postoperative hemorrhage, pain, and the classification and grade of tonsil anatomy, analyzed by univariable and multivariable analyses.

RESULTS

186 of the 337 patients (55.2%) were male and 151 (44.8%) were female; the mean age was 5.59 years. The overall postoperative hemorrhage rate was 4.1%. The mean postoperative VAS score was 4.96. By univariable analysis with logistic regression model, significant associations were found between postoperative hemorrhage and the grade 2 and grade 3 tonsillar lower pole, and grade 3 tonsillar bed. Multivariable analysis with binary logistic regression model also revealed significant associations between postoperative hemorrhage and the grade 2 and grade 3 lower pole (OR: 8.23, 95% CI 1.01-67.37, P = 0.049; OR: 23.86, 95% CI 2.22-56.47, P = 0.009, respectively) and grade 3 tonsillar bed (OR: 14.25, 95% CI 1.46-18.75, P = 0.022). Linear regression analysis showed the associations between postoperative pain and grade 2 and grade 3 lower pole (β: 0.88, 95% CI 0.31-1.32, P = 0.002; β: 1.56, 95% CI 1.29-3.29, P = 0.001, respectively) and grade 3 anterior surface (β: 0.85, 95% CI 0.30-3.07, P = 0.004). Age and upper pole were not associated with the postoperative hemorrhage and pain neither.

CONCLUSION

In the present study, we established a novel classification and 3-grade scale of palatine tonsil anatomy, based on upper pole, anterior surface, lower pole, and tonsillar bed. Furthermore, we revealed for the first time that some anatomical characteristics of tonsils were associated with post-tonsillectomy complications.

Evaluation of the Efficacy of Paracetamol in the Control of Pain After Adenotonsillectomy in the Pediatric Population

Introduction Adenotonsillectomy is a common surgical procedure in otolaryngology. Over the years, several techniques have been developed and modified in order to reduce mortality and morbidity. Postoperative pain control remains controversial. The aim of this study was to evaluate the efficacy of paracetamol alone in the control of postoperative pain. Methods A prospective study was conducted between May 2018 and February 2019, including 76 pediatric patients (age < 18 years), who underwent adenotonsillectomy. The surgeries were performed by the lead author with the same surgical technique. Patients were evaluated one week and one month after surgery through the application of the visual analog pain scale and the number of days of pain was assessed by the need for medication. Results Seventy-six total adenotonsillectomy were performed, with a total of 152 tonsils removed. The majority of patients were male (n=39, 51.3%), with an average age of 6.9 years (min 5, max 15 years). The most frequent surgical indication was sleep breathing disorders, present in 86.9% of the cases. The average duration of postoperative pain was 3 days, with no significant difference between groups (p>0.05). The average intensity of postoperative pain was 3.36 and was higher in patients with infectious criteria as surgical indications (p<0.05). Postoperative bleeding occurred in 3.9% (n=3) of the children, self-limited, without the need for readmission or surgical revision. Conclusion Pain after adenotonsillectomy was more intense in patients undergoing surgery for infectious criteria. Paracetamol used in monotherapy has shown safety and efficacy in controlling postoperative pain.

Clinical potential of pupillary light reflex and heart rate variability parameters as objective indicators of tonsillectomy-induced pain

Establishing objective indicators of subjective pain intensity is important in pain assessment. Pupillary light reflex (PLR) and heart rate variability (HRV) indicate autonomic nervous system (ANS) activity and may serve as pain indicators because pain can affect ANS activity. In this prospective longitudinal study, we aimed to investigate the potential of PLR/HRV parameters as objective indicators of subjective pain intensity after tonsillectomy. Sixty-seven patients undergoing tonsillectomy were enrolled. Subjective pain intensity based on a numeric rating scale (NRS) and eight PLR/HRV parameters were assessed at five time points. We investigated the changes in the NRS values over time. We estimated regression coefficients reflecting parameter changes per unit change in the NRS score using linear mixed-effects models. The mean NRS score was 0 at two pre-surgery time points, 5 on postoperative days (PODs) 1 and 2, and 0 at postoperative week 3. Two parameters (initial pupil size [INIT] and constriction latency [LAT]) showed significant changes on POD1 and POD2 in comparison to baseline data measured at the pre-surgery time point. Among these parameters, only LAT showed no significant changes between POD1 and POD2. Significant regression coefficients with the narrowest 95% confidence intervals were observed for INIT and LAT. Increased NRS scores were associated with decreased INIT and shortened LAT. LAT was a robust indicator of subjective pain intensity. Our patients showed decreased INIT with increased NRS scores, indicating the predominance of the parasympathetic, not sympathetic, tone in pupils. Further studies are required to investigate factors causing this predominance.

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.

Efficacy of topical application of autologous platelet-rich plasma in adult tonsillectomy patients: a randomised control study

OBJECTIVE

Tonsillectomy is a painful surgery performed in cases of recurrent tonsillitis. Application of platelet-rich plasma to diminish the pain and morbidity post-tonsillectomy is gaining importance. This study evaluated post-operative pain and morbidity after autologous platelet-rich plasma application on the tonsil beds during tonsillectomy.

METHOD

Participants were randomised into group 1 (n = 28, peri-operative platelet-rich plasma intervention) and group 2 (n = 28, control). Post-tonsillectomy, patients were assessed (day 0, 1, 2, 3, 7 and 14) for pain, healing and time taken to return to normal activity. Data were analysed by independent t-test and chi-square test with p ≤ 0.05 as the significance level.

RESULTS

A significant decrease in the mean pain score up to day 7 (p < 0.05) and tonsillar fossae healing on days 2 and 3 (p < 0.05) post-tonsillectomy was noted. The majority of the patients returned to their routine activities after a week post-tonsillectomy.

CONCLUSION

Platelet-rich plasma application was effective in accentuating healing and reducing post-tonsillectomy pain and morbidity.

Postoperative Opioid Pain Medication Usage Following Adult Tonsillectomy

INTRODUCTION

The purpose of this study was to determine if short-term, high-quantity opioid use following adult tonsillectomy in active duty military members results in opioid misuse, using a proxy measure of referrals to substance abuse rehabilitation programs.

MATERIALS AND METHODS

An Institutional Review Board-approved retrospective chart review was performed of 741 active duty patients who underwent tonsillectomy between 2012 and 2017. Data collection included preoperative medications within 60 days of surgery, all postoperative opioid prescriptions up to 12 months following surgery, and referrals to substance abuse rehabilitation within a year of surgery.

RESULTS

Out of 741 patients, 658 met inclusion criteria. Fifty-one percent were women and the average age was 26 years. Fifty-nine percent of patients received 5 mg/325 mg oxycodone/acetaminophen as their initial postoperative pain medication. The average number of opioid tablets prescribed was 70 ± 18. Ninety three percent of patients received at least 60 tabs. The refill rate within 30 days of tonsillectomy was 38.6%. In the year following surgery, 25.4% of patients received additional doses of outpatient opioids for other indications. Nineteen patients (2.9%) were referred for substance abuse treatment within 1 year of tonsillectomy: seventeen for alcohol abuse, one for marijuana, and one for alcohol/marijuana. There were no referrals for opiate misuse or abuse.

CONCLUSION

Short-term, high-quantity opioid treatment of post-tonsillectomy pain in active duty adults does not result in long-term opioid misuse, as measured by substance abuse treatment program referrals within a year after surgery. This finding supports the appropriateness of adequate short-term narcotic medication treatment. The long-term readiness of these patients appears unaffected by long-term opioid misuse or abuse. Even with this finding, there is an institutional shift to multi-modality pain management and appropriate opioid reduction to further mitigate the risk of opioid misuse. Extrapolation of these findings to all adult tonsillectomy patients should be done with caution, as there are several protective factors in the active duty population such as stable full-time employment with mandatory random drug screening.

Monopolar tonsillotomy versus cold dissection tonsillectomy in children: Prospective study on postoperative recovery

OBJECTIVES

To compare postoperative self-reported recovery results with monopolar tonsillotomy and cold dissection tonsillectomy in children. To evaluate the feasibility of the monopolar technique in tonsillotomy.

METHODS

Children <12 years undergoing tonsillotomy or tonsillectomy between April 2018 and March 2020 who (with a caregiver) were willing to participate in a two-week follow-up formed the study group. They filled in a questionnaire about pain-related outcomes, return to normal activities, weight changes, complications, and length of home care.

RESULTS

Altogether 166 patients were recruited; 103 (62%) returned the questionnaire. The first pain-free day with tonsillotomy was day 5 and with tonsillectomy day 11. After tonsillotomy, patients returned to normal activities faster, e.g. they were able to eat normally 6.5 days earlier than tonsillectomy patients. During the first postoperative week weight dropped after tonsillectomy, but not after tonsillotomy. The length of home care was 6 days with tonsillotomy and 10 days with tonsillectomy. The incidence of postoperative hemorrhage (including minor bleedings at home) was 14% after tonsillotomy and 32% after tonsillectomy. Hemorrhages needing interventions were 0% with tonsillotomy and 2% with tonsillectomy.

CONCLUSION

Children operated on with monopolar tonsillotomy recovered faster and had less postoperative hemorrhage than those undergoing tonsillectomy. They were able to return earlier to daycare/school and their caregivers back to work. Recovery results with monopolar tonsillotomy were equal to other tonsillotomy techniques reported in the literature, hence the monopolar technique can be considered an alternative method to perform tonsillotomy.

Analgesia for adenotonsillectomy in children: a comparison between peritonsillar infiltration of tramadol, ketamine, and placebo

INTRODUCTION

Post-tonsillectomy pain is mediated by nociceptive C-fibers located at peritonsillar space. Peritonsillar infiltration of medication could relieve post-operative pain blocking the afferent via.

PURPOSE

To evaluate the effect of peritonsillar infiltration of tramadol, ketamine, and placebo on post-operative pain in cases of adenotonsillectomy.

METHODS

This is a double-blind randomized placebo-controlled study. Children ASA I-II aged 3-13 years scheduled for adenotonsillectomy were included in the study. Patients were randomized to receive either 2 mg/kg of peritonsillar tramadol (Group T), 0.5 mg/kg of peritonsillar ketamine hydrochloride (Group K), and 3 mL of peritonsillar saline (Group P). Post-operative pain was recorded using the modified visual analogue scale at 2 h, 6 h, 12 h, and 24 h. Side effects, analgesia requirement, and first oral intake were also recorded.

RESULTS

There were included 112 patients and five were excluded until final evaluation. We evaluated 36 children of Group T, 36 of Group K, and 35 of Group P. Groups were similar regarding to age, weight, height, gender, tonsil and adenoid size, hemodynamic parameters during the surgery, surgery, and anesthesia time. There were no differences between the groups in relation to pain scores, analgesia requirement, or first time of oral intake (p > 0.05). Group T presented a higher incidence of vomit between 2 and 6 h after surgery (p > 0.05).

CONCLUSION

This study showed that peritonsillar infiltration of tramadol or ketamine were not superior to placebo in reducing post-operative pain in children undergone adenotonsillectomy. The use of tramadol increased the risk of nausea and vomit between 2 and 6 h after surgery.

Implications of a Retrospective Study on Weight-Based Risk for Post-Tonsillectomy Pain in Children

PURPOSE

The purpose was to examine if children experience weight-based risks for post-tonsillectomy pain (PTP) in the postanesthesia care unit (PACU).

DESIGN

This retrospective correlational cohort design included a sample of 180 children between the ages of 4 to 12 years who had tonsillectomy and adenoidectomy or tonsillectomy before August 2016; half were obese (OB) or overweight (OW).

METHODS

The sample was obtained from children who had surgery at a large pediatric hospital with an attached outpatient surgical center in North Texas. Children were defined as either OB and OW or non-OB and non-OW based on a cutoff of standardized body mass index z scores of 85th percentile and greater per the National Center for Health Statistics. Pain scores were obtained in the PACU after surgery. Early PTP was defined as the most severe pain experienced by a child in the first 15 minutes after extubation. Prolonged PTP was sustained and uncontrolled pain in the PACU.

FINDINGS

OB and OW status did not increase the likelihood of experiencing early PTP when examined by multiple logistic regression controlling for covariates (adjusted odds ratio, 1.391; P = .369). OB and OW status was associated with longer episodes of prolonged PTP (r_s[178] = 0.16; P = .03). OB and OW children were more likely to experience prolonged PTP in the PACU (χ²[1] = 8.353; P = .004), with these children experiencing an average PTP period twice as long as their peers.

CONCLUSIONS

OB and OW children did experience risk for prolonged PTP, averaging sustained pain for approximately twice as long as other children. The increased risk for prolonged PTP in OB and OW children occurred despite well-managed early PTP with rates that matched those of their peers. No weight-based risk for early PTP was observed. Further research is needed in the area of PTP management in OB and OW children.

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.

The impact of platelet-rich plasma therapy on short-term postoperative outcomes of pediatric tonsillectomy patients

INTRODUCTION

To compare the short-term outcomes of pediatric patients who underwent tonsillectomy alone vs. tonsillectomy plus platelet-rich plasma (PRP) therapy in terms of postoperative pain, appetite status, analgesia requirement, and bleeding complications.

MATERIALS AND METHODS

This study included a total of 80 pediatric tonsillectomy patients (53.8% female, 46.2% male, aged 4-16 years), who were randomly allocated into tonsillectomy alone (TA group; n = 40) and tonsillectomy plus PRP therapy (TPRP group, n = 40) groups. Patient demographic data (age, gender) and postoperative data of visual analog scale (VAS) pain scores (postoperative 2nd hour, 1-10 days), appetite scores (postoperative 1-7 days), and analgesia requirement (postoperative 1-10 days) and bleeding complications were recorded.

RESULTS

A significant gradual decrease was noted in pain scores starting from the 3rd postoperative day reaching 0.0 ± 0.0 and 0.50 ± 0.88 on Day 10 in the TPRP and TA groups, respectively (p < 0.001 for each). Compared to the TA group, the TPRP group was associated with significantly lower pain scores (Day 1 to Day 10), better appetite scores (Day 1 to Day 6), a lower requirement for analgesia (Day1 to Day 10) and fewer common bleeding complications (1 vs. 4 patients) in the postoperative period (p < 0.001 for each).

CONCLUSION

In conclusion, this study of pediatric tonsillectomy patients revealed the superiority of tonsillectomy with PRP over tonsillectomy alone in terms of effectiveness in reducing post-tonsillectomy pain and improving appetite status, together with a lower requirement for analgesia and a reduced risk of post-tonsillectomy bleeding during the first 10 postoperative days.