A randomized, placebo-controlled study of rofecoxib with paracetamol in early post-tonsillectomy pain in adults

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.

Effects of glossopharyngeal nerve block on pain control after tonsillectomy: a systemic review and meta-analysis

BACKGROUND

We investigated the role of perioperative intraoral glossopharyngeal nerve block to minimize postoperative pain in patients undergoing tonsillectomy through a meta-analysis of the relevant literature.

METHODS

We retrieved eight studies from PubMed, Scopus, Embase, Web of Science, and Cochrane databases up to August 2023. We compared perioperative glossopharyngeal nerve block with a control group, in order to examine postoperative pain, analgesic use, and other postoperative morbidities.

RESULTS

Postoperative pain was significantly reduced at 1-4 h (SMD -1.26, 95% CI [-2.35; -0.17], I2 = 94.7%, P = 0.02) and 5-8 hours (SMD -1.40, 95% CI [-2.47; -0.34], I2 = 96.1%, p = 0.01) in the treatment groups compared to the control group. However, glossopharyngeal nerve block showed no efficacy in reducing pain or use of analgesic drugs after 12 h compared to the control group. The incidences of postoperative bleeding (OR 0.95, 95% CI [0.35; 2.52], I2 = 0.0%), local agent toxicity (OR 4.14, 95% CI [0.44; 38.63], I2 = 0.0%), nasal problems (OR 1.25, 95% CI [0.60; 2.61], I2 = 0.0%), postoperative nausea and vomiting (OR 1.35, 95% CI [0.78; 2.33], I2 = 0.0%), swallowing difficulty (OR 1.61, 95% CI [0.76; 3.42], I2 = 56.0%), and voice change (OR 3.11, 95% CI [0.31; 30.80], I2 = 0.0%) were not significantly different between the treatment and control groups. The treatment group showed higher prevalence of respiratory problems and dry mouth compared to control without statistical significance, but a significant increase in throat discomfort (p = 0.02).

CONCLUSION

Intraoral glossopharyngeal nerve block for tonsillectomy did not significantly impact postoperative pain management and was associated with some adverse effects with increases in respiratory problems, dry mouth, and throat discomfort compared to controls.

Role of pre-incisional external bilateral ultrasound guide glossopharyngeal nerve block with diluted bupivacaine mixture in pain management in oropharyngeal surgery: A randomized control trial

The glossopharyngeal nerve block (GNB) was evaluated for pain control together with the magnitude of obtunded gag reflex as a useful clinical sign of GNB.

METHODS

400 patients scheduled for oropharyngeal surgery were randomly allocated into 2 groups (200 patients in each group), Group1 patients received bilateral GNB with 0.125% bupivacaine, 0.5 xylocaine, and 4 mg dexamethasone, while Group 2 patients were enrolled as a control group. Throat pain was evaluated using the visual analog scale at 0.5, 8, and 24 h after surgery, and the degree of gag reflex response was evaluated at the same time points.

RESULTS

Postoperative pain scores at rest and during swallowing were significantly lower in Group 1 versus Group 2. The analgesic efficacy of GNB was intensely interrelated with the magnitude of the obtunded gag reflex (P 0.01).

CONCLUSIONS

GNB is beneficial for pain control in oropharyngeal surgery. An obtunded gag reflex could be a useful clinical sign for a successful GNB analgesic outcome.

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.

Systematic review of analgesics and dexamethasone for post-tonsillectomy pain in adults

BACKGROUND

Intense pain can last several days after tonsillectomy. It is often undertreated and improved analgesic strategies that can be safely used at home are needed.

METHODS

We conducted a systematic review and meta-analysis on the effectiveness of systemic medications used for post-tonsillectomy pain in adult and adolescent (13 yr old) patients. Studies were identified from PubMed, the Cochrane Library, and by hand searching reference lists from studies and review articles. Randomised, double-blind, placebo-controlled studies reporting on pain intensity or use of rescue analgesia were included.

RESULTS

Twenty-nine randomised controlled trials representing 1816 subjects met the inclusion criteria. Follow-up time was ≤24 h in 15 studies, in which the majority were taking nonsteroidal anti-inflammatory drugs. Thirteen studies were suitable for meta-analysis. In pooled analysis, paracetamol, dexamethasone, and gabapentinoids reduced pain intensity on the day of operation. In individual studies, ketoprofen, ibuprofen, lornoxicam, parecoxib, rofecoxib, indomethacin and dextromethorphan reduced pain intensity, need for rescue analgesics, or both on the day of operation. Oral celecoxib for 2 postoperative weeks or i.v. ketamine on the day of operation were not effective at the studied doses. Dexamethasone in multiple doses provided analgesia beyond 1 postoperative day. Pain was moderate to strong in both study and control groups during the first postoperative week.

CONCLUSIONS

Single analgesics and dexamethasone provide only a weak to moderate effect for post-tonsillectomy pain on the day of operation and thus a multimodal analgesic strategy is recommended. Short follow-up times and clinical heterogeneity of studies limit the usefulness of results.

The Effect of Glossopharyngeal Nerve Block on Post-Tonsillectomy Pain of Children; Randomized Controlled Trial

Background

Sensory fibers of the glossopharyngeal nerve supply the tonsillar and peritonsillar areas. Thus, bilateral glossopharyngeal nerve block may alleviate post-tonsillectomy pain and improve postoperative analgesia.

Objectives

The purpose of this clinical trial was to evaluate the effect of glossopharyngeal nerve block on postoperative analgesia in children undergoing adeno-tonsillectomy

Methods

Ninety ASA I-II pediatric patients presented for adeno-tonsillectomy were included in this trial. They were equally divided and randomly assigned to one of two groups: A control group, in which children did not receive a nerve block, and a glossopharyngeal nerve block group, in which children received bilateral glossopharyngeal nerve block after surgery. The postoperative pain score (FLACC score) during rest and swallowing, the time for the first request for rescue analgesia, the total dose consumption of pethidine rescue analgesia, and the incidence of postoperative complications were all assessed. Moreover, response to gag reflex, degree of difficulty in swallowing, and parents’ satisfaction were recorded.

Results

Bilateral glossopharyngeal nerve block in children presented for adeno-tonsillectomy significantly prolonged the time for the first request of rescue analgesia, compared to the control group, reaching 5.833 ± 2.667 hours (P < 0.0001). It also decreased postoperative pethidine consumption to 0.878 ± 0.387 mg/kg (P = 0.0009). Moreover, it significantly decreased the postoperative FLACC score assessed two, four, six, and twelve hours after surgery, during rest and swallowing (P < 0.05). The response to gag reflex and difficulty in swallowing were also significantly decreased (P ≤ 0.0001 and 0.006, respectively). In addition, glossopharyngeal nerve block significantly increased parents’ satisfaction (P = 0.0002), with no significant increase in the incidence of postoperative complications (P > 0.05).

Conclusions

Bilateral glossopharyngeal nerve block in children undergoing adeno-tonsillectomy improved the duration and the quality of postoperative analgesia, decreased swallowing difficulties, and improved parents’ satisfaction.

Glossopharyngeal Nerve Block with Long Acting Local Anaesthetic Agent (Bupivacaine) and It's Effect on Early Post-operative Period in Adult Tonsillectomy: A Prospective Study

We evaluated the benefit of glossopharyngeal nerve block with long acting local anaesthetic like bupivacaine. It was a randomized prospective study. Sixty-four patients were selected and divided into two groups. Group A received bilateral nerve block and Group B received no block. Pain score using Visual Analog Scale (0-100 mm) was assessed at 30 min, 2, 6 and 12 h. In the immediate post operative period pain scores of Group A at rest and swallowing was significantly lower than Group B (p < 0.001 and p < 0.01). Glossopharyngeal nerve block is an important method of reducing post-tonsillectomy pain.

[Postoperative non-opioid analgesics management]

Morphine, which is known as the reference analgesic, has shown its limits. Reducing morphine consumption and multimodal analgesia are integral parts of a modern management of postoperative pain. Combination of several analgesics aims for improving pain control and the ratio between the analgesic effect and the side effects. Nefopam, paracetamol, non-steroids anti-inflammatory drugs and steroids are the most frequently prescribed non-opioid analgesics in France. They can be administered alone or in combination with or without morphine in the postoperative setting. The analgesic benefit of each of these agents and their associations is variable and described in details in this manuscript.

Is speech therapy useful as a complementary treatment for post-tonsillectomy pain?

OBJECTIVES

To evaluate the efficacy of speech therapy for relief of post-tonsillectomy pain in children.

METHODS

Fifty patients who underwent tonsillectomy and were randomly divided into three groups were analyzed in this study. Groups I and II received medical and speech therapy including two different phonemes group, and Group III received only medical therapy. For Group I (20 patients) soft palate phonemes and for Group II (20 patients) lips and gingival phonemes were used. The patients who received medical treatment without speech therapy were used as the control group. Postoperative pain levels were recorded with our standard visual analog scale (VAS) forms for each patient during the postoperative 10 days. The pain score of the patients were compared statistically among the three different groups.

RESULTS

The postoperative pain score was lower in Group I as compared to Group II (p=0.001) and III (p=0.045), and it was statistically significant. There was no significant difference regarding postoperative pain scores between Group II and Group III patients (p=0.356).

CONCLUSION

Speech therapy may cause to strengthen the soft palate muscles and alleviate constant post-tonsillectomy pain. This therapy may be used as a complementary treatment with standard analgesics.

Postoperative analgesia with parecoxib, acetaminophen, and the combination of both: a randomized, double-blind, placebo-controlled trial in patients undergoing thyroid surgery

BACKGROUND

We assessed the analgesic efficacy of parecoxib, acetaminophen, and the combination of both compared with placebo in patients undergoing elective thyroid or parathyroid surgery.

METHODS

We randomized 140 patients to receive one of the following i.v. treatments using a double-blinded double-dummy technique: placebo, 80 mg 24 h(-1) parecoxib, 5 g 24 h(-1) acetaminophen, or 80 mg parecoxib plus 5 g acetaminophen. We provided rescue analgesia with piritramide delivered by a patient-controlled analgesia device. We measured opioid consumption and pain intensity over 24 h after operation.

RESULTS

Patient characteristic data, anaesthetic, and surgical characteristics of the patients in the four groups were similar. Parecoxib, acetaminophen, and the combination significantly reduced opioid requirements during 24 h after surgery [mean (sd) 12.5 (10.9) mg for parecoxib, 14.2 (12.3) mg for acetaminophen, and 11.9 (10.7) mg for combination] compared with placebo [23.5 (15.3) mg, P<0.05]. However, the combination of parecoxib and acetaminophen did not have any advantage over individual drugs in terms of opioid consumption in our trial (P>0.05).

CONCLUSIONS

Parecoxib and acetaminophen effectively reduce postoperative opioid requirements after thyroid or parathyroid surgery. The combination of these drugs is not associated with a further reduction in opioid consumption.

Analgetikakombinationen zur postoperativen Schmerztherapie

BACKGROUND

The supplementation of an opioid by a non-opioid analgesic is a widely accepted technique for the treatment of postoperative pain. However, it is still unclear whether a combination of different non-opioids has an advantage in terms of an improved analgesia and/or a reduction of the opioid-related adverse effects.

METHODOLOGY

A systematic analysis of the literature was performed searching for randomized, controlled trials studying the effects of a combination of two non-opioid analgesics in order to reduce postoperative opioid requirements and/or postoperative pain. Significant reduction of the postoperative opioid requirement and/or postoperative pain were defined as main rating criteria. To facilitate comparisons between the trials, the relative (proportional) reduction of postoperative opioid administration and the relative reduction of postoperative pain were calculated on defined pain scales.

RESULTS

A total of 25 trials were identified, mainly studies comparing non-steroidal anti-inflammatory drugs (NSAIDs) with paracetamol. Only 3 trials found a statistically improved analgesic efficacy and 15 studies did not show any relevant improvement or the combination group was only significantly superior to one of the groups receiving monotherapy. A further seven studies could not be evaluated due to methodological issues. There was no evidence for a significant reduction of opioid-induced adverse effects.

CONCLUSION

A combination of non-opioid analgesics, in particular NSAIDs with paracetamol, cannot be recommended at present due to the lack of data showing improved effectiveness.

The effects of glossopharyngeal nerve block on postoperative pain relief after tonsillectomy: the importance of the extent of obtunded gag reflex as a clinical indicator

BACKGROUND

We evaluated the efficacy of glossopharyngeal nerve block (GNB) for the control of post-tonsillectomy pain in adult patients, and correlated the extent of obtunded gag reflex as a clinical indicator of GNB with the extent of pain relief.

METHODS

Seventy-five patients undergoing tonsillectomy received bilateral GNB with 0.75% ropivacaine with epinephrine (Group R), 0.5% bupivacaine with epinephrine (Group B) at the end of the operation, or no intervention (Group C). To evaluate the effects of GNB, we assessed throat pain (100 mm visual analog scale) and severity of gag reflex response 0.5, 8, and 24 h after surgery.

RESULTS

In the immediate postoperative period, pain scores at rest and when swallowing in Groups R and B were significantly lower than those in Group C (21 +/- 17 and 23 +/- 13 vs 42 +/- 16, 28 +/- 22 and 32 +/- 19 vs 62 +/- 14, P < 0.001). The analgesic effect of GNB was strongly correlated with the extent of obtunded gag reflex (P < 0.01).

CONCLUSIONS

GNB is a useful method for the palliation of post-tonsillectomy pain. An obtunded gag reflex response may be a clinical indicator for analgesia from GNB.

Painless tonsillectomy

PURPOSE OF REVIEW

Even though pediatric tonsillectomy is a well accepted treatment for upper airway obstruction or recurrent tonsillar infection, the painful recovery of this operation is unwelcome. As more studies are published on the beneficial effects of tonsillectomy, the number of tonsillectomies performed is likely to increase. It would behoove any surgeon performing this operation to be aware of the available options for post/perioperative pain control.

RECENT FINDINGS

New techniques used to perform tonsillectomy, innovative adjuvant medical therapy and other tools are reviewed.

SUMMARY

The search for 'the painless tonsillectomy' continues. Finding a technique that works best for each surgeon is paramount to successful tonsillectomy. Patient comfort, surgical time, complications such as bleeding and regrowth of tonsillar tissue, or recurrence of symptoms that lead to the initial operation should all be considered in the surgeon's choice of a particular tonsillectomy technique. Medical therapies such as corticosteroids in the perioperative period are well accepted as a pain adjuvant. Newer adjuvants include the use of pretonsillectomy injection of mixtures that include local anesthetics with opioids and clonidine. The use of nonsteroidal antiinflammatory drugs appears to be helpful for pain, but controversial regarding bleeding. Another successful strategy used to decrease pain perception is distraction.

Pain after elective arthroscopy of the knee: a prospective, randomised, study comparing conventional NSAID to coxib

Although outpatient knee arthroscopy is probably by far the most frequently performed orthopaedic procedure, there are limited guidelines or consensus concerning the peroral postoperative pain management. A diversity of analgesics both in potency and action is prescribed. The purpose of the present investigation was to grade the pain and need for rescue medication during the first 4 days after the knee arthroscopy, comparing a conventional nonsteroidal anti-inflammatory drug (NSAID) with a selective cox-II-inhibitor (coxib) as postoperative pain medication. One hundred and twenty-two patients scheduled for primary elective knee arthroscopy in general anaesthesia were randomised to either a NSAID (lornoxicam) or a selective cox-II-inhibitor (rofecoxib) postoperatively. Pain ratings and the need for rescue medication were followed for four consecutive days. Side effects were also registered. The need for rescue analgesics was highest the evening after surgery, when 42% of patients required one, or more, oral additional analgesics. The use of rescue medication decreased with time and 30, 25, 16 and 11% of the patients required additional analgesics for day 1 to 4, respectively, still 50% of all patients required at some point one or more rescue analgesics. Overall pain ratings were low, and showed similar pattern with evening and day, 50% of all patients required at some point one or more rescue analgesics. We found, however, no differences in pain ratings, or need for rescue analgesics between the two groups, conventional NSAID and coxib as well as no difference in side-effect profile. In conclusion, patients do require proper pain management also after minor outpatient surgical procedures such as knee arthroscopy. The traditional NSAIDs seem to be the first choice for analgesic and anti-inflammatory effects, when needed after elective arthroscopy of the knee.

State of the art of paracetamol in acute pain therapy

PURPOSE OF REVIEW

This review highlights new insights into the mechanism of action of paracetamol (acetaminophen) and therapeutic schemes.

RECENT FINDINGS

Paracetamol, a centrally acting inhibitor of cyclooxygenases, has weak peripheral effects recently demonstrated. Paracetamol is nevertheless devoid of side effects commonly observed with the use of nonsteroidal anti-inflammatory drugs. Paracetamol is available by the oral, rectal, and, more recently, intravenous routes of administration. Paracetamol efficacy is surgical procedure dependent. The analgesic efficacy of a 2-g starting dose of intravenous paracetamol is superior to the recommended dose of 1 g in terms of magnitude and duration of analgesic effect. The usual scheme of administration (1 g every 6 hours) has a less than 10-mg sparing effect on 24-hour morphine consumption and consequently does not significantly reduce morphine side effects. The combination of nonsteroidal anti-inflammatory drugs and paracetamol is more effective than paracetamol alone, but the benefit is unclear when compared with nonsteroidal anti-inflammatory drugs used alone.

SUMMARY

Further studies are required to assess the opioid-sparing effect and complementary analgesic effect of new intravenous paracetamol therapeutic schemes.