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Harshvardhan R, Gupta A, Sharma S. Efficacy of Sucralfate in Alleviating Post Tonsillectomy Symptoms and Morbidity: A Comparative Randomized Interventional Study. Indian J Otolaryngol Head Neck Surg 2022; 74:5536-5542. [PMID: 36742847 PMCID: PMC9895478 DOI: 10.1007/s12070-021-02894-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/26/2021] [Indexed: 02/07/2023] Open
Abstract
Pain following tonsillectomy still remains the main concern of topic and it occurs along with sever ear pain and trismus until and unless the exposed and inflamed mucosa gets covered with the regenerated mucosa. To study the efficacy of sucralfate in alleviating postoperative pain and morbidity following tonsillectomy. Subjects included in our study were patients which were fulfilling criteria for tonsillectomy and were admitted under the Department of Otorhinolaryngology, SMS Medical College and Hospital, Jaipur from 1st July 2019 to 31st March 2020. 64 patients were evaluated and were randomly allocated into study and control group based on the administration of topical sucralfate. 64 patients who were admitted for tonsillectomy under the Department of Otorhinolaryngology, SMS Medical College and Hospital, Jaipur from 1st July 2019 to 31st March 2020 were included in study. Patients were evaluated and were randomly allocated into study and control group based on the administration of topical sucralfate. The incidence of throat pain and otalgia showed significant difference among both the group following postoperative day 2 onwards. On postoperative day 2, significant difference in trismus was also found. Effective alleviation of pain not only improves early dietary intake of the patients but also allays fear of apprehensive parents.
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Affiliation(s)
- Rekha Harshvardhan
- Department of Otorhinolaryngology, SMS Medical College, Jaipur, Rajasthan India
| | - Ajay Gupta
- Department of Community Medicine, SMS Medical College, Jaipur, Rajasthan India
| | - Shraddha Sharma
- Department of Otorhinolaryngology, SMS Medical College, Jaipur, Rajasthan India
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Shih MC, Long BD, Pecha PP, White DR, Liu YC, Brennan E, Nguyen MI, Clemmens CS. A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy. World J Otorhinolaryngol Head Neck Surg 2022; 9:9-26. [PMID: 37006744 PMCID: PMC10050970 DOI: 10.1002/wjo2.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/23/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research. Data Sources PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley). Methods A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs. Results One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons. Conclusion Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.
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Affiliation(s)
- Michael C. Shih
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
- Baylor College of Medicine Houston Texas USA
| | - Barry D. Long
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
- Department of Otolaryngology—Head and Neck Surgery Virginia Commonwealth University School of Medicine Richmond Virginia USA
| | - Phayvanh P. Pecha
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
| | - David R. White
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
| | - Yi‐Chun C. Liu
- Department of Otolaryngology—Head and Neck Surgery Baylor College of Medicine Houston Texas USA
- Department of Surgery ‐ Division of Pediatric Otolaryngology Texas Children's Hospital Houston Texas USA
| | - Emily Brennan
- Department of Research and Education Services Medical University of South Carolina Library Charleston South Carolina USA
| | - Mariam I. Nguyen
- Charleston County School of the Arts North Charleston South Carolina USA
| | - Clarice S. Clemmens
- Department of Otolaryngology—Head and Neck Surgery Medical University of South Carolina Charleston South Carolina USA
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Singh NV, Gabriele GA, Wilkinson MH. Sucralfate as an Adjunct to Analgesia to Improve Oral Intake in Children With Infectious Oral Ulcers: A Randomized, Double-Blind, Placebo-Controlled Trial. Ann Emerg Med 2021; 78:331-339. [PMID: 33867179 DOI: 10.1016/j.annemergmed.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 11/26/2022]
Abstract
STUDY HYPOTHESIS We hypothesized that sucralfate along with oral analgesics (acetaminophen or ibuprofen) administered in the emergency department leads to a clinically significant improvement in oral intake in children with acute infectious oral ulcers. METHODS This was a randomized, double-blind, placebo-controlled trial of sucralfate versus placebo conducted between 2017 and 2018 in an urban pediatric emergency department. Children aged 6 months to 5 years with acute, infectious oral ulcers and poor oral intake received either acetaminophen at 15 mg/kg or ibuprofen at 10 mg/kg and were then randomized to receive sucralfate at 20 mg/kg per dose up to 1 g or a placebo solution. The primary outcome was oral fluid intake within 60 minutes of medication administration. The secondary outcomes were repeat ED visits, length of stay in ED, intravenous hydration rate, admission rate, adverse event rate, and emergency physician's determination of the adequacy of oral intake. RESULTS One hundred subjects with mild dehydration (clinical dehydration score of 1) and a median age of 1.38 years were enrolled and analyzed (49 in the sucralfate group and 51 in the placebo group). Oral intake 1 hour after drug administration was similar in both the groups: the median intake in the sucralfate group was 9.7 mL/kg and 10.7 mL/kg in the placebo group (difference -1 mL/kg; 95% confidence interval [CI] -2.0 to 4.8). According to the emergency physician's report, the secondary outcomes were significant only for adequate oral intake: 71% in the sucralfate group versus 88% in the placebo group (difference -16.8%; 95% CI -32.2 to -1.4). CONCLUSION Sucralfate as an adjunct to oral analgesics was not superior to placebo in improving oral intake in children with acute oral infectious ulcers.
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Affiliation(s)
- Nidhi V Singh
- Department of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, TX.
| | | | - Matthew H Wilkinson
- Department of Pediatric Emergency Medicine, University of Texas Austin Dell Medical School, Austin, TX
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Saei S, Sahebnasagh A, Ghasemi A, Akbari J, Alipour A, Lashkardoost H, Yaghobi Joybari A, Nejad Dadgar F, Ala S, Salehifar E. Efficacy of sucralfate ointment in the prevention of acute proctitis in cancer patients: A randomized controlled clinical trial. CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 11:410-418. [PMID: 33680383 PMCID: PMC7911762 DOI: 10.22088/cjim.11.4.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Acute radiation proctitis (ARP) is a usual adverse effect in patients undergoing pelvic radiotherapy. The symptoms include diarrhea, rectal blood or mucus discharge, fecal urgency and tenesmus with pain. Sucralfate, an aluminum-based salt of sucrose octasulfate, is a cytoprotective agent that forms a coating barrier at injured sites by adhering to mucoproteins. It has been used in topical management of a wide variety of local lesion. This study was designed to evaluate the preventive effect of rectal sucralfate on acute radiotherapy induced proctitis. Methods: Seven percent sucralfate ointment was prepared for topical use. Drug quantification, chemical stability and microbial limit tests were performed carefully. In this randomized double blind placebo controlled trial, fifty-seven patients with pelvic malignancies undergoing radiotherapy were allocated to receive either 1 g of sucralfate or 1 g of placebo, given as a twice daily ointment, one day before and during radiotherapy for six weeks. The eligible patients were evaluated based on RTOG acute toxicity criteria and the following ARP symptoms weekly: rectal hemorrhage, diarrhea, rectal pain, and fecal urgency. The influence of symptoms on lifestyle was also recorded weekly. Results: Acute proctitis was significantly less prevalent in patients in the sucralfate group. The incidence of rectal bleeding (P=0.003), diarrhea (P=0.002), rectal pain (P=<0.001) and fecal urgency (P=0.002) was significantly less common in the sucralfate group. No statistical significant difference was observed for radiotherapy induced cystitis in the placebo and sucralfate groups (P=0.27). Conclusion: This study suggests that sucralfate7% ointment reduces the incidence of symptoms associated with acute radiation proctitis.
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Affiliation(s)
- Sara Saei
- Student Research Committee, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, Faculty of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Arash Ghasemi
- Emam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Jafar Akbari
- Pharmaceutical Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abbas Alipour
- Department of Epidemiology, Faculty of Medicine, Community Medicine Department, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hossein Lashkardoost
- School of Public Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Ali Yaghobi Joybari
- Pharmaceutical Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Farid Nejad Dadgar
- Pharmaceutical Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Shahram Ala
- Pharmaceutical Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ebrahim Salehifar
- Gastrointestinal Cancer Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
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Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 76:947-961. [PMID: 33201518 PMCID: PMC8247026 DOI: 10.1111/anae.15299] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/12/2022]
Abstract
Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.
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Affiliation(s)
- N Aldamluji
- Department of Adult Anaesthesiology, Sidra Medicine, Qatar
| | - A Burgess
- Department of Otolaryngology Head and Neck Surgery, Com Maillot-Hartmann Private Hospital, Neuilly sur Seine, France
| | - E Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - J Raeder
- Department of Anaesthesiology, Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - H Beloeil
- Department of Anaesthesiology and Critical Care, Université Rennes, Rennes, France
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Maroda AJ, Coca KK, McLevy-Bazzanella JD, Wood JW, Grissom EC, Sheyn AM. Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery. Otolaryngol Clin North Am 2020; 53:819-830. [PMID: 32622548 DOI: 10.1016/j.otc.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.
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Affiliation(s)
- Andrew J Maroda
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kimberly K Coca
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jennifer D McLevy-Bazzanella
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua W Wood
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erica C Grissom
- Department of Anesthesiology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 400, Memphis, TN 38163-2242, USA; Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Kisser U, Lill C, Adderson-Kisser C, Patscheider M, Stelter K. Total versus subtotal tonsillectomy for recurrent tonsillitis - a prospective randomized noninferiority clinical trial. Acta Otolaryngol 2020; 140:514-520. [PMID: 32049573 DOI: 10.1080/00016489.2020.1725112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: For many years experts have called for randomized controlled trials to resolve the question whether tonsillectomy, which is associated with significant comorbidity, can be replaced by partial tonsillectomy in patients with recurrent tonsillitis.Objective: To find out whether subtotal tonsillectomy is a suitable therapeutic alternative to total tonsillectomy in adult patients with recurrent episodes of acute tonsillitis.Material and methods: Study design - Single-blind prospective non-inferiority randomized clinical trial with intraindividual design. Setting - 80 patients were recruited at a tertiary referral center. Subjects - Adult patients with recurrent tonsillitis received total tonsillectomy on one side and subtotal tonsillectomy on the other side after randomization. Main outcome measure was frequency of postoperative tonsillitis on the side of subtotal tonsillectomy and postoperative pharyngitis in the former tonsil area on the side of total tonsillectomy. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00015628).Results: Within 12 months none of the subjects suffered from recurrent tonsillitis after subtotal tonsillectomy. Subtotal tonsillectomy caused less pain than total tonsillectomy.Conclusion: Subtotal tonsillectomy might be an alternative treatment option associated with lower morbidity than total tonsillectomy in adults with recurrent tonsillitis.
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Affiliation(s)
- Ulrich Kisser
- Department of Otorhinolaryngology, Head and Neck Surgery, University Clinic Halle, Halle, Germany
| | - Claudia Lill
- Department of Otorhinolaryngology, Head and Neck Surgery, Evangelical Hospital, Vienna, Austria
| | | | - Martin Patscheider
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Munich, Munich, Germany
| | - Klaus Stelter
- ENT, Head and Neck Surgery, ENT Center Mangfall-Inn, Rosenheim, Germany
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London K, Watson H, Kwok S, Nanan R, Liu A. Oral sucrose for analgesia in children aged between 3 months and 3 years undergoing transurethral bladder catheterisation: A randomised, double-blinded, clinical trial. J Paediatr Child Health 2020; 56:207-214. [PMID: 31317627 DOI: 10.1111/jpc.14559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 03/08/2019] [Accepted: 06/13/2019] [Indexed: 11/27/2022]
Abstract
AIM Many children admitted to hospital undergo invasive, painful and stressful procedures, including children who are not toilet trained undergoing transurethral bladder catheterisation (TUBC). Oral sucrose is commonly given to children to reduce procedural pain. In this study, we evaluated the effectiveness of oral sucrose in reducing procedural pain in children aged between 3 months and 3 years undergoing TUBC. METHODS This study was a randomised, double-blind, placebo-controlled study conducted at Nepean Hospital, Sydney, Australia from June 2005 to June 2010. A total of 40 participants requiring TUBC for diagnostic evaluation were included. The participants were randomly assigned to receive 4 mL of 75% oral sucrose (n = 20) or a placebo (sterilised water) (n = 20). The primary outcomes were changes in two paediatric pain scale scores (the FLACC pain scale and the OUCHER pain scale), assessed by the parent/guardian(s), the doctor performing the TUBC and the nurse assisting. The secondary outcomes were physiological (changes in heart rate) and behavioural pain (crying) indicators. RESULTS Of the outcome measures, 65% favoured the oral sucrose group, 31% favoured the placebo group, and 4% found no difference between the oral sucrose and placebo groups. CONCLUSION While the trends favouring the sucrose group in this study were encouraging, as the results were not statistically significant, there was insufficient evidence to demonstrate the effectiveness of oral sucrose in reducing procedural pain in children aged between 3 months and 3 years undergoing TUBC.
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Affiliation(s)
- Kevin London
- Department of Nuclear Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Hamish Watson
- Department of Nuclear Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Samson Kwok
- Department of Paediatrics, Nepean Hospital, Sydney, New South Wales, Australia
| | - Ralph Nanan
- Department of Paediatrics, Nepean Hospital, Sydney, New South Wales, Australia
| | - Anthony Liu
- Department of Paediatrics, Nepean Hospital, Sydney, New South Wales, Australia
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Kim DH, Jang K, Lee S, Lee HJ. Update review of pain control methods of tonsil surgery. Auris Nasus Larynx 2019; 47:42-47. [PMID: 31672398 DOI: 10.1016/j.anl.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 10/01/2019] [Accepted: 10/07/2019] [Indexed: 11/17/2022]
Abstract
Pain after tonsil surgery is troublesome because it causes discomfort. In addition, handling patients with postoperative pain is challenging to otolaryngologists. Many laboratory studies have assessed the use of analgesics and surgical techniques to discover methods for effective control of postoperative pain associated with tonsil surgery. In this review article, we summarize and provide a comprehensive overview of current methods for the control of pain after tonsil surgery based on findings of recent studies. Although powered intracapsular tonsillotomy is not popular yet, it seems to be an effective option among various surgical techniques. More discussion about powered intracapsular tonsillotomy should be done in the future. On the other hand, surgery with a harmonic scalpel, fibrin glue, or cryoanalgesia seems ineffective. When reviewing medical treatment methods, the use of nonsteroidal anti-inflammatory drugs, steroids, and/or gabapentin/pregabalin seems to be effective. However, the use of opioid (especially codeine) for children should be avoided because of possible respiratory insufficiency. Ketorolac is dangerous because of the risk of hemorrhage. We should continue to focus on the development of novel postoperative pain control techniques with no or low complications.
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Affiliation(s)
- Dong-Hyun Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Incheon St. Mary's Hospital, College of medicine, The Catholic University of Korea, #56, Dongsuro, Bupyung-gu, Seoul 21431, Republic of Korea
| | - Kyungil Jang
- Department of Otorhinolaryngology-Head and Neck Surgery, Incheon St. Mary's Hospital, College of medicine, The Catholic University of Korea, #56, Dongsuro, Bupyung-gu, Seoul 21431, Republic of Korea
| | - Seulah Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Incheon St. Mary's Hospital, College of medicine, The Catholic University of Korea, #56, Dongsuro, Bupyung-gu, Seoul 21431, Republic of Korea
| | - Hyun Jin Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Incheon St. Mary's Hospital, College of medicine, The Catholic University of Korea, #56, Dongsuro, Bupyung-gu, Seoul 21431, Republic of Korea.
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Rodríguez MC, Villamor P, Castillo T. Assessment and management of pain in pediatric otolaryngology. Int J Pediatr Otorhinolaryngol 2016; 90:138-149. [PMID: 27729121 DOI: 10.1016/j.ijporl.2016.09.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/10/2016] [Accepted: 09/13/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction. OBJECTIVES The aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services. METHODOLOGY Narrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016. RESULTS 129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services. CONCLUSIONS We present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.
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Affiliation(s)
- Maria Claudia Rodríguez
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Perla Villamor
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia.
| | - Tatiana Castillo
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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Stelter K. Tonsillitis and sore throat in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2014; 13:Doc07. [PMID: 25587367 PMCID: PMC4273168 DOI: 10.3205/cto000110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others. A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens). The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy. On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age. The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery. The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes. All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All "hot" techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage. Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe. The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
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Affiliation(s)
- Klaus Stelter
- Dep. of Otorhinolaryngology, Head and Neck Surgery, Grosshadern Medical Centre, University of Munich, Munich, Germany
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Siupsinskiene N, Žekonienė J, Padervinskis E, Žekonis G, Vaitkus S. Efficacy of sucralfate for the treatment of post-tonsillectomy symptoms. Eur Arch Otorhinolaryngol 2014; 272:271-8. [PMID: 24691853 DOI: 10.1007/s00405-014-3023-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 03/20/2014] [Indexed: 12/20/2022]
Abstract
Pain after tonsillectomy remains the main issue of postoperative morbidity and the search for an effective post-tonsillectomy analgesic is of increasing relevance. The aim of this study was to evaluate the effectiveness of topical sucralfate during an early post-tonsillectomy period. Fifty patients of both genders from 6 to 58 years submitted to tonsillectomy or adenotonsillectomy were randomly included into either a sucralfate treatment group (N = 25) or into a control group (N = 25). Patients of the sucralfate group received topical sucralfate four times a day for 7 days. No topical treatment was applied to patients of the control group. A systemic analgesic was standardized. Post-tonsillectomy symptoms, including throat pain, odynophagia and otalgia, were evaluated during the period of seven postoperative days. Secondary outcomes were analgesic use, well being in general, return to regular daily activities, secondary hemorrhage and side effects of sucralfate. This study revealed that during the period of the second to seventh postoperative days average throat pain scores of the sucralfate using patients were significantly lower than those of the control group patients (p < 0.05); the same could be applied to odynophagia scores during the period of all seven postoperative days (p < 0.01) and otalgia scores from the 4th postoperative day (p < 0.05). The sucralfate group patients also had a significantly smaller need for analgesics, better scores of well being in general and early return to regular daily activities with no side effects of the treatment. Topical sucralfate could be recommended for the everyday clinical practice as a safe, adjuvant medicine of treatment during the period of the first post-tonsillectomy week.
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Affiliation(s)
- Nora Siupsinskiene
- Department of Otorhinolaryngology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania,
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Adherence of Randomized Trials Within Children's Surgical Specialties Published During 2000 to 2009 to Standard Reporting Guidelines. J Am Coll Surg 2013; 217:394-399.e7. [DOI: 10.1016/j.jamcollsurg.2013.03.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/02/2013] [Accepted: 03/05/2013] [Indexed: 02/07/2023]
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The effects of levobupivacaine infiltration on post-tonsillectomy pain relief in adults: a single-blinded, randomized, and controlled clinical study. Eur Arch Otorhinolaryngol 2012; 270:761-6. [PMID: 23053376 DOI: 10.1007/s00405-012-2194-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 09/19/2012] [Indexed: 10/27/2022]
Abstract
The aim of this prospective single-blinded and controlled study is to evaluate the efficacy of levobupivacaine infiltration on post-tonsillectomy pain relief in adults. The study was conducted with 40 adult patients who underwent tonsillectomy. These patients were randomized in either study group (SG) who received levobupivacaine infiltration to peritonsillary fossae prior to surgery or control group (CG) with no medication. After surgery, all the patients were queried for pain scores by visual analog scale. In addition, the volume of intraoperative bleeding, the duration of operation, the severity of postoperative complications, and the amount of analgesic requirement were the other outcome measures of this study. There were significant differences between groups regarding pain scores for the first 24 h in favor of SG. The analgesic requirement was also significantly lower in SG (p = 0.009). Although there was a sustained decrement at pain score during first 24 h for SG, however, the change from baseline score (immediate score) for each time interval revealed no significance compared to CG. In addition, the duration of operation and the volume of intraoperative bleeding were similar (p = 0.64 and p = 0.165). In conclusion, preincisional infiltration of levobupivacaine is a safe and reliable method for post-tonsillectomy pain reduction in adults. However, more in-depth, double-blinded and placebo controlled studies are required to elucidate its long term benefits.
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Efficacy of 10 % Sucralfate Ointment in the Reduction of Acute Postoperative Pain After Open Hemorrhoidectomy: A Prospective, Double-Blind, Randomized, Placebo-Controlled Trial. World J Surg 2012; 37:233-8. [DOI: 10.1007/s00268-012-1805-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics 2010; 126:e1168-98. [PMID: 20921070 DOI: 10.1542/peds.2010-1609] [Citation(s) in RCA: 338] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference. OBJECTIVES To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility. METHODS Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori. RESULTS From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS. CONCLUSIONS For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.
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Affiliation(s)
- Deborah Tomlinson
- Child Health Evaluative Services, Hospital for Sick Children, Toronto, Ontario, Canada.
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Miura MS, Saleh C, de Andrade M, Assmann M, Ayres M, Lubianca Neto JF. Topical sucralfate in post-adenotonsillectomy analgesia in children: a double-blind randomized clinical trial. Otolaryngol Head Neck Surg 2009; 141:322-8. [PMID: 19716007 DOI: 10.1016/j.otohns.2009.05.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 05/12/2009] [Accepted: 05/29/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Tonsillectomy, with or without adenoidectomy, is one of the most common surgical procedures in pediatric otolaryngology. Despite its relative simplicity, pain is the main cause of morbidity in the postoperative period. We determined the effect of topical sucralfate on reduction of oropharyngeal pain in children submitted to adenotonsillectomy. Secondary outcomes were otalgia, analgesic use, type of diet, secondary bleeding, vomiting, fever, and weight loss. STUDY DESIGN Double-blind, randomized clinical trial. SETTING Tertiary hospital. SUBJECTS AND METHODS Eighty-two children of both sexes between four and 12 years old submitted to adenotonsillectomy were evaluated. They were allocated to receive topical sucralfate or placebo in intraoperative and postoperative periods four times a day for five days. Pain was measured through faces pain scale. RESULTS Reduction in oropharyngeal pain was significant with use of sucralfate during five days of evaluation (mean, 95% confidence interval, and P value); day 1: 2.05, 1.53-2.58, P = 0.000; day 2: 2.1, 1.51-2.70, P = 0.001; day 3: 1.44, 0.88-1.99, P = 0.003; day 4: 1.13, 0.58-1.55, P = 0.027; day 5: 0.67, 0.26-1.04, P = 0.021). There was no difference in secondary outcomes. CONCLUSION We found beneficial effect of use of sucralfate in reduction of oropharyngeal pain in the postoperative period of adenotonsillectomy. However, topical sucralfate does not have a potent effect to the point of being utilized as a single analgesic treatment. Because it is simple, safe, tolerated, and low-cost, it is an important tool as adjuvant treatment of post-tonsillectomy pain.
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Affiliation(s)
- Mauricio Schreiner Miura
- Department of Medical Surgery of Universidade Federal de Ciências da Saúde de Porto Alegre and Division of Pediatric Otorhinolaryngology at Hospital da Criança Santo Antênio, Programa de Pós-Graduação em Ciências Médicas-Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Adjuvant use of liquid alginate suspension for post-tonsillectomy morbidity: Double-blind randomized clinical trial of efficacy. Otolaryngol Head Neck Surg 2009; 140:652-6. [DOI: 10.1016/j.otohns.2008.12.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 12/15/2008] [Accepted: 12/26/2008] [Indexed: 11/24/2022]
Abstract
Objective: To evaluate the efficacy of liquid alginate suspension in alleviating post-tonsillectomy morbidity in adult patients. Methods: A prospective, double-blind, randomized, placebo-controlled study comparing the effect of liquid alginate suspension with placebo was performed on 40 patients who underwent tonsillectomy at Derince State Hospital, Kocaeli, Turkey. The patients were randomly chosen, and each used liquid alginate suspension four times daily or a placebo solution at the same regimen. Tonsillectomy was performed under general anesthesia by cold dissection and suture ligation. Patients were examined at postoperative days 1, 3, 5, and 7 for healing, instructed to note the amount of analgesics used, and asked to mark the visual analog score of throat pain every day for a week. Results: The study group had statistically significant lower pain scores at day 2 ( P = 0.03). Study group required less analgesic than the control group during the study period, but the difference was statistically different only on day 2 ( P = 0.003) day. Healing was statistically significant on day 5 ( P = 0.03) in the study group. Conclusion: Use of the antireflux suspensions in patients undergoing tonsillectomy may be effective in reducing postoperative morbidity in adjunct with classic analgesics.
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