Pharmacologic management of post-tonsillectomy pain in children

Suprazygomatic Maxillary Nerve Blocks and Opioid Requirements in Pediatric Adenotonsillectomy: A Randomized Clinical Trial

Importance

Pain management following pediatric adenotonsillectomies is opioid-inclusive, leading to potential complications.

Objective

To investigate the use of suprazygomatic maxillary nerve (SZMN) blocks to reduce pain and opioid use after pediatric intracapsular adenotonsillectomy and to measure recovery duration and incidence of complications.

Design, Setting, and Participants

This was a randomized, blinded, prospective single-center tertiary pediatric hospital that included 60 pediatric patients (2-14 years old) scheduled for intracapsular adenotonsillectomy from November 2021 to March 2023. Patients were excluded for having combined surgical procedures, developmental delay, coagulopathy, chronic pain history, known or predicted difficult airway, or unrepaired congenital heart disease. Participants were randomized to receive bilateral SZMN blocks (block group) or not (control group).

Intervention

SZMN block administered bilaterally under general anesthesia for intracapsular adenotonsillectomy.

Primary Outcomes and Measures

Opioid consumption, FLACC (Face, Legs, Activity, Cry, Consolability) scores, and rates of opioid-free postanesthesia care unit (PACU) stay. Secondary outcomes were recovery duration and incidence of adverse effects, ie, nausea, vomiting, block site bleeding, and emergency delirium.

Results

The study population included 53 pediatric patients (mean [SD] age, 6.5 [3.6] years; 29 [55%] females; 24 [45%] males); 26 were randomly assigned to the SZMN block group and 27 to the control group. The mean (SD) opioid morphine equivalent consumption during PACU stay was 0.15 (0.14) mg/kg for the 27 patients in the control group compared with 0.07 (0.11) mg/kg for the 26 patients in the block group (mean difference, 0.08; 95% CI, 0.01-0.15; Cohen d, 0.64). The block group had a higher incidence of opioid-free PACU stays (n = 7 patients; 58%) compared with the control group (n = 15 patients; 26%) (mean difference, 32%; 95% CI, 5%-53%). Patients in the block group experienced lower FLACC scores (0.7 vs 1.6; mean difference, 0.9; 95% CI, 0.2-1.6; Cohen d, 0.7). The overall occurrence of adverse events was similar in the 2 groups, with no reported nerve block-related complications.

Conclusions and Relevance

The results of the randomized clinical trial indicate that SZMN blocks are a useful adjunct tool for managing postoperative pain in pediatric intracapsular adenotonsillectomy. Use of these blocks during adenotonsillectomy provided clinically meaningful reductions of postoperative opioid consumption with a low risk of complications.

Trial Registration

ClinicalTrials.gov Identifier: NCT04797559.

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.

Case report: Avoidant/restrictive food intake disorder after tonsillectomy

Background

Avoidant Restrictive Food Intake Disorder (ARFID) is a newly classified eating disorder that requires further understanding of its presentation. There is no previous report of ARFID in a child post-tonsillectomy. ARFID may be a potential negative outcome for children following oropharyngeal surgery.

Case presentation

A female child aged 10 years and 2 months presented with ARFID associated with depression, anxiety and nutritional deficiency following tonsillectomy. She had more difficulty in swallowing solids than fluids and had repeated vomiting and spitting food after chewing it. She became dehydrated and malnourished with a BMI of 10.5 and was misdiagnosed with myasthenic gravis.

Conclusions

To our knowledge, this is the first case report of ARFID in a child post-tonsillectomy. We discuss the pathophysiology of ARFID, which remains elusive, and recommend psychiatric assessment when evaluating children post operative tonsillectomy.

Comparative Analysis of Nebulized Versus Intravenous Fentanyl for Pain Control After Tonsillectomy: A Double-Blind, Randomized, Controlled Trial

OBJECTIVES

Effective posttonsillectomy analgesia is crucial for patient comfort and recovery. Fentanyl, notable for its potency, rapid action, and lipophilicity, has been successfully used in various procedures through multiple administration routes. However, the use of its nebulized form for posttonsillectomy pain has not been extensively explored. This study sought to compare the analgesic efficacy, onset time, and complications between nebulized and intravenous fentanyl in posttonsillectomy patients.

METHODS AND METHODS

In this randomized controlled trial, adult patients who underwent tonsillectomy were assigned to either an intravenous fentanyl group (1 mcg/kg) or a nebulized fentanyl group (4 mcg/kg). In both groups, fentanyl was administered when pain scores exceeded three. Pain levels were monitored every 5 minutes until they fell below four. The study also recorded the duration until the next analgesia request and noted complications (such as respiratory depression, bradycardia, chest tightness, drowsiness, nausea, pruritus, sweating, and flushing) within 24 hours. Patient exclusions were based on predetermined criteria.

RESULTS

From an initial cohort of 59 patients, 22 in the intravenous group and 27 in the nebulizer group were eligible for analysis after applying the exclusion criteria. The nebulizer group exhibited a significantly prolonged period before the next analgesia request, with a median of 683.5 minutes (interquartile range 260-1440), in contrast to the 326.7 minutes (145.0-504.7) observed in the intravenous group (P = .009). The time to achieve a pain score less than 4 and the incidence of side effects did not differ significantly between the groups.

CONCLUSION

Nebulized fentanyl provided a longer duration of analgesia than intravenous fentanyl in posttonsillectomy pain management, with similar onset times and side effect profiles. These findings underscore the potential of nebulized fentanyl as an effective alternative for pain control in posttonsillectomy patients.

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.

Current Pediatric Tertiary Care Practices Following Adenotonsillectomy: An Update

OBJECTIVE

Adenotonsillectomy is a common procedure performed in children, and the practice patterns at academic centers have been evolving with the publication of updated societal guidelines. In this study, we assess perioperative practice patterns at tertiary care children's hospitals for children undergoing adenotonsillectomy.

METHODS

A cross-sectional 18-question survey distributed in July of 2022 recruited responses through August 25, 2022. The division chiefs of 70 pediatric otolaryngology groups at tertiary care children's hospitals across the United States and Canada were surveyed. Division chiefs submitted survey responses on behalf of the group practice patterns for children undergoing adenotonsillectomy. The main measure was survey responses from the division chiefs of pediatric otolaryngology reporting group practice.

RESULTS

The survey response rate was 46%. Eighty-eight percent of groups reported an official adenotonsillectomy admission policy. Commonly reported admission criteria included age (93%) and obesity (59%). Eighty-eight percent of groups defined severe obstructive sleep apnea as apnea-hypopnea index ≥10. Only 41% of groups required a child to be observed sleeping on room air prior to ambulatory discharge. Ninety-seven percent of groups reported routinely obtaining preoperative polysomnography in a variety of clinical settings.

CONCLUSIONS

Many children's hospitals report an official admission policy following adenotonsillectomy. Despite a decade passing since the initial publication of the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines, there remains great variability in the practice patterns for both preoperative polysomnography and postoperative monitoring and admission. These results highlight an opportunity for an improved unified approach to perioperative pediatric adenotonsillectomy practice.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:2931-2936, 2024.

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

OBJECTIVE

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

MATERIALS & METHODS

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

RESULTS

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

CONCLUSION

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

The post-operative tonsillectomy (POPT) study: A multi-centre prospective paediatric cohort study

OBJECTIVES

Tonsillectomy is the most common operation performed by otolaryngologists in the UK, despite this we have a poor understanding of the post-operative recovery. We aimed to investigate post-operative bleeding and pain following paediatric tonsillectomy using a patient diary.

DESIGN

Prospective observational cohort study.

SETTING

Multi-centre study involving 12 secondary and tertiary otolaryngology units across the North of England. Patients were recruited from 1st March 2020 to 30th June 2022. Multilevel ordered logistic regression model statistics were performed.

PARTICIPANTS

Children (≥4 years, ≤16 years) undergoing tonsillectomy (with or without adenoidectomy) for benign pathology.

MAIN OUTCOME MEASURES

Frequency and severity of post-operative bleeding. Intensity and pattern of post-operative pain.

RESULTS

In total 297 children were recruited, with 91 (30.6%) diaries eligible for analysis. Post-operative bleeding occurred in 44% of children. Most frequently blood in the saliva was reported (82.9%). Increasing age significantly increased bleeding odds by 17% per year (p = .001). Bleeding frequency decreased with higher surgeon grade (p = .003) and when performing intracapsular coblation tonsillectomy (p = .02) compared with other techniques. Lower age and intracapsular coblation tonsillectomy, against other techniques, significantly reduced rates of pain post-operatively (p < .0001 and p = .0008).

CONCLUSION

A high level of low-level post-operative bleeding was observed. Pain scores remained high for 5 days post-operatively then gradually reduce to normal by day 13. Intracapsular coblation tonsillectomy appears to be superior to all other techniques in terms of reducing post-operative bleeding and pain. These findings should be used to guide patients in the consent process to inform them of the expected nature of post-surgical recovery.

Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

OBJECTIVE

Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience.

METHODS

A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions.

RESULTS

Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses.

DISCUSSION

In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates.

IMPLICATIONS FOR PRACTICE

Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.

Treatment of recurrent acute tonsillitis-a systematic review and clinical practice recommendations

Background

There is an ongoing debate on the indications for tonsil surgery in both children and adults with recurrent acute tonsillitis. The aim is to provide practical recommendations for diagnostics and treatment for recurrent acute tonsillitis including evidence-based decision making for tonsillectomy.

Methods

A systematic literature search in PubMed, Embase, Web of Science, and ScienceDirect from 2014 until April 2023 resulted in 68 articles. These were the basis for the review and a comprehensive series of consensus statements on the most important diagnostics and indications for both non-surgical and surgical therapy. A consensus paper was circulated among the authors and members of the International Head and Neck Scientific Group until a final agreement was reached for all recommendations.

Results

The differentiation between sore throat and tonsillitis patient episodes is mostly not feasible and hence is not relevant for diagnostic decision making. Diagnostics of a tonsillitis/sore throat episode should always include a classification with a scoring system (Centor, McIssac, FeverPAIN score) to estimate the probability of a bacterial tonsillitis, mainly due to group A streptococcus (GAS). In ambiguous cases, a point-of-care test GAS swab test is helpful. Consecutive counting of the tonsillitis/sore throat episodes is important. In addition, a specific quality of life score (Tonsillectomy Outcome Inventory 14 or Tonsil and Adenoid Health Status Instrument) should be used for each episode. Conservative treatment includes a combination of paracetamol and/or non-steroidal anti-inflammatory drugs. In case of high probability of bacterial tonsillitis, and only in such cases, especially in patients at risk, standard antibiotic treatment is initiated directly or by delayed prescription. Tonsillectomy is indicated and is highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years. An essential part of surgery is standardized pain management because severe postoperative pain can be expected in most patients.

Conclusion

It is necessary to follow a stringent treatment algorithm for an optimal and evidence-based treatment for patients with recurrent acute tonsillitis. This will help decrease worldwide treatment variability, antibiotic overuse, and avoid ineffective tonsillectomy.

A service evaluation of the impact of parental information provision on analgesia administration at home posttonsillectomy

INTRODUCTION

Tonsillectomy and adenotonsillectomy are together the most common pediatric surgical procedure and are increasingly performed as day cases. Postoperative pain is commonly severe for 1-2 weeks, but parental analgesia concerns lead to poor analgesia prescription compliance and under administration. This service evaluation assessed parental compliance with analgesia, elicited parental concerns, and obtained parental suggestions for improving the current written advice.

METHODS

Telephone questionnaires were completed on postoperative Days 3/4 and 7 with 42 parents of pediatric (adeno)-tonsillectomy patients over a 6-month period, peri-pandemic. The questionnaire collected categorical data on: analgesia prescribed and administered, the child's symptoms, and healthcare resource use. Qualitative data on barriers to analgesia administration and suggestions for written advice improvement were grouped thematically.

RESULTS

Sore throats were reported by 93.3% parents between discharge and Day 3/4 but only 43.3% parents had 100% compliance with regular paracetamol and ibuprofen in the same time period. Parents frequently avoided morphine administration, expressing concerns about side effects, addiction, and previous experience. Parents were also concerned about using ibuprofen, discrepancies between weight-based and bottle instruction doses, and the length of the analgesia course. Parents would like further written information and reassurance on these topics as well as guidance on tapering or stopping analgesics and whether to wake their child at night.

CONCLUSION

The breadth of unmet information needs identified in this service evaluation, alongside parental suggestions, will be used to improve the current written advice with the aim to improve the postoperative pain experience at home. These include information on length of analgesic course, safety of ibuprofen and paracetamol coadministration for analgesia, and details about morphine administration, including safety, side effects, and indication.

Is Laser Better than Cold Steel (Dissection and Snare) for Tonsillectomy?

OBJECTIVE

To analyse the surgical outcome of CO2 laser assisted tonsillectomy with the cold steel (conventional dissection and snare) tonsillectomy.

MATERIALS AND METHODS

This prospective, non-randomised, single blind study was conducted in 25 cases suffering with recurrent tonsillitis. The left tonsillectomy was performed with CO2 laser while the right tonsil was excised using cold steel method (conventional dissection and snare method). The surgical time, blood loss and post-operative pain for each method was recorded and analysed.

RESULTS

CO2 laser tonsillectomy had highly significant less intra-operative blood loss (41.8ml vs. 78.8ml with p = 0.001) and postoperative pain levels on postoperative day 1,3, and 5 ( p value of 0.013, 0.006 and 0.000 respectively) as compared to cold steel method. However; there was no statistically significant difference in operative time between the two techniques (p > 0.05).

CONCLUSION

CO2 laser tonsillectomy appeared to be better technique than cold steel in terms of intra-operative haemorrhage and pain.

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.

PRP-Fibrin Glue for Pain Reduction and Rapid Healing in Tonsillectomy

INTRODUCTION

Many ongoing challenges have been applied to reduce the considerable postoperative pain and increase wound healing after tonsillectomy, but they are still not optimally managed. This study applied autologous platelet-rich plasma (PRP) & platelet-rich fibrin glue (PRFG) to reduce pain and increase wound healing.

MATERIALS AND METHODS

PRP & PRFG were prepared from 26 patients' blood. At the end of the tonsillectomy, one tonsillar bed was selected randomly, PRP was injected, PRFG was applied topically on the bed wound, and the other sites were left untreated. The treated and untreated tonsillar beds were compared for pain and wound healing the next day, 3rd day, 6th day, 9th day, and 15th day.

RESULTS

There were no complications during and after the injection. The mean age was 24.76 ±5.54 years. In the treated beds in comparison to untreated beds, pain decreased marginally in 1st day (intervention:4.5±2.54, control:5.53±2.94, P-value=0.18) and 3rd day (intervention:3.92±2.96, control:4.8±2.82, P-value=0.276), and significantly in 6th day (intervention:2.3±2.46, control:3.92±2.6, P-value=0.026), 9th day (intervention:1.26±1.48, control:2.76±2.4, P-value=0.009) and 15th day (intervention:0.73±1.07, control:1.84±2.36, P-value=0.08) after surgery. Healing did not change in 1st day (P-value=1), changed marginally in 3rd day (P-value=0.2), and increased significantly in 6th day (P-value=0.001), 9th day (P-value=0.006), and 15th day (P-value=0.004) after surgery.

CONCLUSIONS

Autologous PRP injection & PRFG application offer an effective, safe, and non-invasive method for reducing pain and increasing wound healing after tonsillectomy.