Recovery after tonsillectomy in adults: a three-week follow-up study

Opioid and non-opioid analgesic prescribing practices for pediatric adenotonsillectomy in a tertiary care center

IMPORTANCE

The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions.

OBJECTIVE

To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits.

DESIGN

Descriptive analysis of retrospective cohort data.

SETTING

Tertiary academic healthcare institution.

PARTICIPANTS

Pediatric patients <18yo undergoing adenotonsillectomy between 2013 and 2016.

INTERVENTIONS/EXPOSURES

Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery.

MAIN OUTCOMES AND MEASURES

Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022.

RESULTS

200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p < 0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p > 0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.

Intracapsular tonsillectomy in the treatment of recurrent and chronic tonsillitis in adults: a protocol of a prospective, single-blinded, randomised study with a 5-year follow-up (the FINITE trial)

INTRODUCTION

The standard surgical treatment for recurrent or chronic tonsillitis is extracapsular tonsillectomy. Recent studies show that intracapsular tonsillectomy has the potential to reduce the postoperative morbidity of patients undergoing tonsil surgery. The Finnish Intracapsular Tonsillectomy (FINITE) trial aims to provide level I evidence to support the hypothesis that the recovery time from tonsil surgery can be reduced with intracapsular tonsillectomy. Additionally, from this trial, major benefits in quality of life, reduction of postoperative complications, treatment costs and throat symptoms might be gained.

METHODS AND ANALYSIS

The FINITE trial is a prospective, randomised, controlled, patient-blinded, three-arm clinical trial. It is designed to compare three different surgical methods being extracapsular monopolar tonsillectomy versus intracapsular microdebrider tonsillectomy versus intracapsular coblation tonsillectomy in the treatment of adult patients (16-65 years) suffering from recurrent or chronic tonsillitis. The study started in September 2019, and patients will be enrolled until a maximum of 200 patients are randomised. Currently, we are in the middle of the study with 125 patients enrolled as of 28 February 2022 and data collection is scheduled to be completed totally by December 2027. The primary endpoint of the study will be the recovery time from surgery. Secondary endpoints will be the postoperative pain scores and the use of analgesics during the first 3 weeks of recovery, postoperative haemorrhage, quality of life, tonsillar remnants, need for revision surgery, throat symptoms, treatment costs and sick leave. A follow-up by a questionnaire at 1-21 days and at 1, 6, 24 and 60 months will be conducted with a follow-up visit at the 6-month time point.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Medical Ethics Committee of the Hospital District of Southwest Finland (reference number 29/1801/2019). Results will be made publicly available in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03654742.

Ibuprofen prescription following adult tonsillectomy reduces postoperative opioid use

BACKGROUND

Based on a 2018 American Academy of Otolaryngology - Head and Neck Surgery survey, an average of 37 tablets of opioid medication, or about a week's worth of medication, were prescribed after adult tonsillectomy. Nearly 15% of patients will still be taking opioids one year after an initial weeklong prescription, according to data from the Centers for Disease Control and Prevention. Non-steroidal anti-inflammatory medications have traditionally been avoided in adult tonsillectomy patients due to concern for increased bleeding risk from platelet dysfunction, despite little evidence supporting this claim. This study sought to demonstrate that ibuprofen prescriptions after tonsillectomy could be a safe and effective way to reduce postoperative opioid use.

METHODS

This study was a retrospective chart review of patients undergoing tonsillectomy with one surgeon over three years. Half of the patients received a prescription for postoperative opioid medications and were counseled against taking ibuprofen. The other half of patients were prescribed ibuprofen following surgery and only provided with opioid analgesia as a rescue medication. The New Mexico Prescription Monitoring System was used to verify opioid prescriptions. Descriptive statistics and logistic regression were used to analyze the data.

RESULTS

Ninety-nine patients were included in analysis, with 53 in the first group that did not receive ibuprofen and 46 in the second group that did receive ibuprofen. There was no difference in the bleeding rate between the two groups. Significantly fewer patients in the ibuprofen group filled postoperative opioid prescriptions when compared to the group that did not receive ibuprofen (40% vs. 96.2%, p < 0.0001, OR = 0.02).

CONCLUSION

Ibuprofen is a safe and effective analgesic following adult tonsillectomy and significantly reduces the proportion of patients who must fill a postoperative opioid prescription.

Time to Functional Recovery After Laser Tonsillotomy Performed Under Local Anesthesia vs Conventional Tonsillectomy With General Anesthesia Among Adults: A Randomized Clinical Trial

IMPORTANCE

Carbon dioxide laser tonsillotomy performed under local anesthesia may be an effective and less invasive alternative than dissection tonsillectomy for treatment of tonsil-related afflictions.

OBJECTIVE

To compare functional recovery and symptom relief among adults undergoing tonsillectomy or tonsillotomy.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at 5 secondary and tertiary hospitals in the Netherlands from January 2018 to December 2019. Participants were 199 adult patients with an indication for surgical tonsil removal randomly assigned to either the tonsillectomy or tonsillotomy group.

INTERVENTIONS

For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia, whereas tonsillectomy consisted of total tonsil removal performed under general anesthesia.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to functional recovery measured within 2 weeks after surgery assessed for a modified intention-to-treat population. Secondary outcomes were time to return to work after surgery, resolution of primary symptoms, severity of remaining symptoms, surgical complications, postoperative pain and analgesics use, and overall patient satisfaction assessed for the intention-to-treat population.

RESULTS

Of 199 patients (139 [70%] female; mean [SD] age, 29 [9] years), 98 were randomly assigned to tonsillotomy and 101 were randomly assigned to tonsillectomy. Recovery within 2 weeks after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for recovery after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.5). Two weeks after surgery, 72 (77%) patients in the tonsillotomy group were fully recovered compared with 26 (57%) patients in the tonsillectomy group. Time until return to work within 2 weeks was also shorter after tonsillotomy (median [IQR], 4.5 [3.0-7.0] days vs 12.0 [9.0-14.0] days; hazard ratio for return after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.4.). Postoperative hemorrhage occurred in 2 patients (2%) in the tonsillotomy group and 8 patients (12%) in the tonsillectomy group. At 6 months after surgery, fewer patients in the tonsillectomy group (25; 35%) than in the tonsillotomy group (54; 57%) experienced persistent symptoms (difference of 22%; 95% CI, 7%-37%). Most patients with persistent symptoms in both the tonsillotomy (32 of 54; 59%) and tonsillectomy (16 of 25; 64%) groups reported mild symptoms 6 months after surgery.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that compared with tonsillectomy performed under general anesthesia, laser tonsillotomy performed under local anesthesia had a significantly shorter and less painful recovery period. A higher percentage of patients had persistent symptoms after tonsillotomy, although the intensity of these symptoms was lower than before surgery. These results suggest that laser tonsillotomy performed under local anesthesia may be a feasible alternative to conventional tonsillectomy in this population.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL6866 (NTR7044).

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Monitoring the recovery time of children after tonsillectomy using commercial activity trackers

An observational prospective feasibility study in which children received a tracker 2 weeks before a tonsillectomy and were required to wear it until four weeks postoperatively. The parents used a diary to log the estimated steps of their child. As primary endpoint, the compliance of complete datasets was compared between the tracker and the diary. As secondary endpoints, the agreement of steps between tracker and diary, and the recovery time after tonsillectomy were analyzed.Twenty-four patients (50% male) with a median age of 6 years were recruited. The tracker had a complete dataset compliance of 91.7% in the pre-operative and 58.3% in postoperative period, whereas the diary's compliance was 62.5% in the pre-operative and 12.5% in the postoperative period. The difference of 29.2% and 45.8% in the pre-operative and postoperative periods between the tracker and the diary was significant (p < 0.005). The tracker and diary had a mean agreement difference of 1063 steps per day. Mean recovery time was 21 days after tonsillectomy.Conclusion: The results of this pilot study support the use of a tracker in terms of compliance and practicability. Consumer-level activity trackers are a viable alternative to conventional manual logging for clinical use in pediatric research.Trial registration: ClinicalTrials.gov Identifier: NCT03174496 What is known: • Consumer-level activity trackers are already used in clinical research to monitor steps and physical activity. • The use of consumer-level activity trackers in clinical studies has mostly been validated in the adult population. What is new: • This study proves the feasibility of using physical activity trackers in a pediatric population before and after a surgical intervention. • Recovery of a patient could be assessed with an activity tracker.

Pathogenic role of palatine tonsils in palmoplantar pustulosis: A review

Palmoplantar pustulosis (PPP) is characterized by symmetrical, erythematous, scaly plaques, with numerous, sterile, non-bacterial, pinpoint pustules, which are restricted to the palms and soles. Because several reports have described the efficacy of tonsillectomy for improvement in PPP skin lesions, we consider that PPP is tonsil-induced autoimmune/inflammatory syndrome (TIAS) while other factors are also involved in the pathogenesis of PPP. Here, the association between PPP pathogenesis and TIAS was examined, with a focus on results of previous studies. PPP patients show a hyperimmune response to indigenous bacteria such as α-streptococci, due to impaired immunological tolerance towards such organisms. Such a novel immune response leads to T-cell activation through the abnormal expression of secondary stimulation molecules, including cytotoxic T-lymphocyte-associated antigen 4, inducible T-cell co-stimulator and Smad7, in the tonsils of PPP patients. Activated tonsillar T cells express cutaneous lymphocyte antigen (CLA), CCR6 and β1-integrin, enter the blood circulation and are recruited to PPP skin lesions. Within lesions, T cells roll onto endothelial cells through the interaction between CLA and E-selectin, migrate into the extravascular area through β1-integrin-vascular cell adhesion molecule 1 binding, and assemble in the skin through CCL20-CCR6 binding. Hyperimmune responses to autoantigens such as keratin and heat shock proteins could also be involved in PPP pathogenesis, through the stimulation of the T-helper 17 reaction.

The Efficacy of Intravenous Magnesium Sulfate versus Intravenous Paracetamol on Children Posttonsillectomy Pain and Analgesic Requirement: A Randomized Controlled Study

Background:

One of the most common complications of tonsillectomy is pain, which leading to delayed recovery and later hospital discharge.

Aims:

We intended to compare the efficacy of magnesium sulfate versus paracetamol on the posttonsillectomy pain and analgesic requirement.

Settings and Design:

This study design was a prospective randomized controlled double-blinded clinical study.

Patients and Methods:

A total of 60 children with the American Society of Anesthesiologists physical status classes I and II, aged 3–12 years, scheduled for tonsillectomy were randomly divided into two groups each group contains 30 patients: (Group M): received an initial loading dose of magnesium sulfate 30 mg/kg over 15 min started with induction followed by continuous infusion of 10 mg/kg/h for 1 h regardless of the operation time and (Group P): received paracetamol infusion 10 mg/kg started with induction and continued for 1 h. Postoperatively, a blinded postanesthesia care unit (PACU) nurse observed the quality of analgesia using the face, legs, activity, cry, and consolability pain scores, bleeding, and sedation.

Statistical Analysis Used:

Student's t-test and Chi-square test were used for analysis.

Results:

Regarding postoperative pain, there was a statistically significant difference between the two groups at the time of admission in PACU (P = 0.025) as children who experienced pain already had taken rescue analgesic to alleviate pain. There was a statistically significant difference between the two groups regarding the need for analgesics (P = 0.038). There was no statistically significant difference regarding bleeding and sedation scores between the two study groups.

Conclusions:

Magnesium sulfate provided better postoperative analgesia and reduced need for analgesics after tonsillectomy compared to paracetamol, and regarding the incidence of bleeding and the degree of sedation the outcome in both groups was readily comparable.

Gabapentin in the Management of Pain following Tonsillectomy: A Randomized Double-Blind Placebo-Controlled Trial

Objective To determine if a single dose of oral gabapentin given prior to tonsillectomy decreases postoperative morbidity. Study Design Prospective randomized double-blind placebo-controlled trial. Setting Southern District Health Board University Hospitals, New Zealand, over a 10-month period. Subjects and Methods Seventy-three adults undergoing tonsillectomy were randomized to receive either a single preoperative dose of oral gabapentin (600 mg) or placebo. A standard analgesic protocol was prescribed for 14 postoperative days. The primary outcome was a patient-assigned visual analog scale pain score during rest and swallow; secondary outcomes were analgesic consumption, nausea, vomiting, and return to normal diet and activities. Complications and adverse effects were also recorded. Results Thirty-seven participants were allocated to the placebo group and 36 to the gabapentin group. After withdrawals, data were analyzed from 31 in the placebo group and 27 in the gabapentin group. Pain scores between groups were not significantly different within the first 6 hours. The gabapentin group recorded significantly higher pain scores between days 5 and 10 (maximal difference, day 8: 17.6 mm; effect size, -8.87; P = .03; 95% CI, -16.883 to -0.865). There was no significant difference in swallow pain scores or early postoperative fentanyl consumption. Consumption of paracetamol ( P = .01 at day 13 and P = .004 at day 14) and codeine ( P < .05 at days 3-5, 7, 8, 10, 14) was higher in the gabapentin group. No significant difference between groups was found for the other outcomes. Conclusions Preemptive gabapentin (600 mg) was associated with greater postoperative pain scores and analgesic consumption following adult tonsillectomy when compared with placebo.

Adult tonsillectomy: postoperative pain depends on indications

Introduction

Intense pain is one of the most important postoperative complaints after tonsillectomy. It is often described by patients as comparable to the pain that accompanies an acute tonsillitis. Although recurrent tonsillitis is the most frequent indication for surgery, many tonsillectomies are performed due to other indications and these patients may be unfamiliar with such pain.

Objective

To verify whether individuals with recurrent tonsillitis experience different post-tonsillectomy pain intensity than those with other indications for surgery, with no history of episodes of acute tonsillitis.

Methods

A total of 61 tonsillectomies were performed under general anesthesia, using a potassium titanyl phosphate (KTP) laser (to eliminate the potential influence on the study results of forceful dissection of fibrotic tonsils in patients with history of recurrent tonsillitis) and multiple ligations of blood vessels within the tonsillar beds. The patients received 37.5 mg Tramadoli hydrochloridum + 325 mg Paracetamol tablets for 10 days. Postoperative variables included the duration of hospital stay, postoperative hemorrhage and readmission rate. The patients reported pain intensity on consecutive days, pain duration, weight loss on postoperative day 10, character, intensity and duration of swallowing difficulties, and the need for additional doses of painkillers. Healing was also assessed. Capsular nerve fibers were histologically examined in the resected tonsils by immunostainings for general and sensory markers.

Results

Indications for the surgery were: recurrent acute tonsillitis (34 patients), no history of recurrent tonsillitis: focus tonsil (20) and intense malodour (7). Pain intensity on postoperative days 3–4 and incidence of readmissions due to dehydration were significantly higher in the group with no history of recurrent tonsillitis. No significant differences in relative densities of protein gene product (PGP) 9.5- and calcitonin gene-related peptide (CGRP)-immunoreactive nerve fibers were observed.

Conclusion

Patients with recurrent tonsillitis qualified for tonsillectomy reported lower pain intensity than those without recurrent tonsillitis and the pain scores were unrelated to nerve fibers density.

Present-day challenges and future solutions in postoperative pain management: results from PainForum 2014

This paper is a summary of presentations on postoperative pain control by the authors at the 2014 PainForum meeting in People's Republic of China. Postoperative pain is often untreated or undertreated and may lead to subsequent chronic pain syndromes. As more procedures migrate to the outpatient setting, postoperative pain control will become increasingly more challenging. Evidence-based guidelines for postoperative pain control recommend pain assessment using validated tools on a consistent basis. In this regard, consistency may be more important than the specific tool selected. Many hospitals have introduced a multidisciplinary acute pain service (APS), which has been associated with improved patient satisfaction and fewer adverse events. Patient education is an important component of postoperative pain control, which may be most effective when clinicians chose a multimodal approach, such as paracetamol (acetaminophen) and opioids. Opioids are a mainstay of postoperative pain control but require careful monitoring and management of side effects, such as nausea, vomiting, dizziness, and somnolence. Opioids may be administered using patient-controlled analgesia systems. Protocols for postoperative pain control can be very helpful to establish benchmarks for pain management and assure that clinicians adhere to evidence-based standards. The future of postoperative pain control around the world will likely involve more and better established APSs and greater communication between patients and clinicians about postoperative pain. The changes necessary to implement and move forward with APSs is not a single step but rather one of continuous improvement and ongoing change.

The efficacy of TachoComb on reducing postoperative complications after tonsillectomy in children

OBJECTIVE

A fibrinogen/thrombin-based collagen fleece (TachoComb) is a powerful topical hemostatic agent that has been widely used in various surgical specialties with a favorable outcome. The purpose of this study was to investigate the effect of TachoComb application on postoperative complications after tonsillectomy.

MATERIALS AND METHODS

A total of 1633 children had undergone tonsillectomy with or without adenoidectomy were included in this study. After removal of both tonsils, 1057 patients (64.7%) were treated with TachoComb on the tonsillectomy site and 576 without TachoComb. Post-tonsillectomy pain, hemorrhage rates, re-admission rates, and emergency surgery rates for post-tonsillectomy hemorrhage were evaluated between patients who received TachoComb and those who did not.

RESULTS

TachoComb treatment significantly reduced post-tonsillectomy pain and emergency surgery rates for post-tonsillectomy hemorrhage. However, postoperative hemorrhage rate and re-admission rates for post-tonsillectomy hemorrhage were not statistically significant between TachoComb treatment group and control group. No patients had complications or adverse reactions after TachoComb treatment.

CONCLUSIONS

The use of TachoComb after tonsillectomy significantly reduces pain and emergency surgery for severe post-tonsillectomy hemorrhage without an apparent adverse effect. Therefore, TachoComb may be a useful adjuvant in terms of efficacy and safety after tonsillectomy.

Korean hand therapy for tonsillectomy pain in children

OBJECTIVES

Severe throat pain can result from tonsillectomy and last up to 10 days in children. Codeine has recently been banned by the FDA in light of a recently recognized risk of death in these patients. Acupuncture has previously been associated with decreased pain in children after tonsillectomy. However, about 1 in 5 patients will refuse traditional acupuncture because of fear of needles. We explored Korean Hand Therapy (KHT), an acupuncture technique which does not involve needles, to see if this would also be associated with pain relief and be more widely accepted by children.

METHODS

This was a retrospective review of children who underwent tonsillectomy over a 4-month window. No narcotics were prescribed after surgery. Patients who wanted help with pain relief were offered KHT. Perceived pain level was assessed before and after the KHT treatment. Following the 10-day recovery for tonsillectomy, patients or their parents were queried as to how long the pain relief from the KHT intervention was perceived to last.

RESULTS

Fifty-six children underwent tonsillectomy; 29 of these patients (1-14 years) presented for pain relief after tonsillectomy and received KHT. 100% of patients (29 of 29) who were offered KHT accepted the intervention. The mean reported pain level before KHT was 5.03 (SD=2.69) out of 10. This fell to 3.06 (SD=3.15) after KHT. Statistical analyses supported the general conclusion that pain reports decline after KHT in the sampled population. 15 patients who received KHT - or their parents - provided a post-recovery report for how long they believed the KHT intervention lasted. The mean duration of perceived KHT benefit was 78.20h, though the standard deviation was large (64.38h). With the exception of one child reporting a slight increase in pain, no adverse effects were associated with KHT.

CONCLUSIONS

The data tentatively suggest KHT is associated with decreases in perceived pain after tonsillectomy and is widely accepted by children. These data - combined with the cost effectiveness, safety and ease of administering KHT - suggest that further studies exploring the effectiveness of KHT for pain relief after tonsillectomy are merited.

The effectiveness of pregabalin for post-tonsillectomy pain control: a randomized controlled trial

BACKGROUND

Although various analgesics have been used, postoperative pain remains one of the most troublesome aspects of tonsillectomy for patients.

OBJECTIVE

The aim of the present study was to evaluate the effectiveness of premedication using pregabalin compared with placebo (diazepam) on postoperative pain control in patients undergoing tonsillectomy.

METHODS

Forty-eight adult patients were randomly divided into a control group and a pregabalin group. Preoperatively, patients in the control group received 4 mg diazepam orally as placebo, whereas those in the pregabalin group received 300 mg pregabalin orally. All participants were provided with patient-controlled analgesia using fentanyl for 24 hours after surgery. Postoperative pain treatment included acetaminophen 650 mg three times daily for 8 postoperative days. The primary outcome measure was the total amount of patient-controlled fentanyl consumption after tonsillectomy. Secondary outcome measures were the number of injections of ketorolac tromethamine (each 30 mg) requested by patients, pain scores, overall satisfaction scores, drowsiness, nausea, dizziness, headache, and vomiting after the surgery. P < 0.05 was considered statistically significant.

RESULTS

The total amount of fentanyl demanded decreased significantly in the pregabalin group (P < 0.001). There were no significant differences in the number of ketorolac tromethamine injections, pain scores, overall satisfaction scores, drowsiness, nausea, dizziness, headache, and vomiting between the two groups.

CONCLUSION

Administration of 300 mg pregabalin prior to tonsillectomy decreases fentanyl consumption compared with that after 4 mg diazepam, without an increased incidence of adverse effects.

TRIAL REGISTRATION

KCT0001215.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Acupuncture instead of codeine for tonsillectomy pain in children

OBJECTIVES

Severe throat pain can result from tonsillectomy and last up to 10 days in children. Codeine elixir has long been used for pain relief, but has recently been banned by the Food and Drug Administration due to a recently recognized risk of death. We explored acupuncture as an alternative means of pain relief for children and adolescents after tonsillectomy.

METHODS

This was a retrospective review of children and adolescents who underwent tonsillectomy over a three-month period. No narcotics were prescribed after surgery. Patients who wanted help with pain relief were offered acupuncture. Perceived pain level was assessed before and after the acupuncture treatment. Following the 10-day recovery for tonsillectomy, patients or their parents were queried as to how long the pain relief from acupuncture intervention was perceived to last.

RESULTS

56 children and adolescents underwent tonsillectomy in the three-month window selected for the retrospective review. 31 of these patients (ranging from 2 to 17 years in age) received an acupuncture intervention for postoperative pain. The mean reported pain level before acupuncture was 5.52 (SD = 2.28) out of 10. This fell to 1.92 (SD = 2.43) after acupuncture. Statistical analysis supported the general conclusion that pain reports decline after acupuncture in the sampled population. However, the limitations of the methodology and the sample suggest that this generalization should be treated as preliminary. 17 patients or their parents provided a post-recovery report for how long they believed the acupuncture intervention lasted. The mean duration of perceived acupuncture benefit was 61.24 h, though the standard deviation was large (64.58 h) with about 30% of patients reporting less than three hours of benefit and about 30% reporting more than 60 h. No adverse effects were observed as a result of acupuncture treatments.

CONCLUSIONS

The data tentatively suggest that acupuncture decreases perceived pain in children and adolescents after tonsillectomy. These data - combined with the cost effectiveness, safety and ease of administering acupuncture - suggest that further studies exploring the effectiveness of acupuncture in juveniles after tonsillectomy are merited.

Post tonsillectomy pain: can honey reduce the analgesic requirements?

Background

Tonsillectomy with or without adenoidectomy is one of the most common surgical procedures performed worldwide, especially for children. Oral honey administration following tonsillectomy in pediatric cases may reduce the need for analgesics via relieving postoperative pain.

Objectives

The aim of this study was to evaluate the effects of honey on the incidence and severity of postoperative pain in patients undergoing tonsillectomy.

Patients and Methods

A randomized, double blind, placebo controlled study was performed. One hundred and four patients, who were older than eight, and were scheduled for tonsillectomy, were divided into two equal groups, honey and placebo. Standardized general anesthesia, and postoperative usual analgesic, and antibiotic regimen were administrated for all patients. Acetaminophen plus honey for the honey group, and acetaminophen plus placebo for the placebo group were given daily. They began to receive honey or placebo when the patients established oral intake.

Results

The difference between acetaminophen and acetaminophen plus honey groups was statistically significant both for visual analogue scale (VAS), and number of painkillers taken within the first three postoperative days. The consumption of painkillers differed significantly in every five postoperative days. No significant difference was found between groups regarding the number of awaking at night.

Conclusions

Postoperative honey administration reduces postoperative pain and analgesic requirements in patients after tonsillectomy. As the side effects of honey appear to be negligible, consideration of its routine usage seems to be beneficial along with routine analgesics.

Six years of evidence-based adult dissection tonsillectomy with ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection

OBJECTIVE

To conduct an adequately powered, prospective, randomised, controlled trial comparing adult dissection tonsillectomy using either ultrasonic scalpel, bipolar electrocautery, bipolar radiofrequency or 'cold steel' dissection.

METHODS

Three hundred patients were randomised into four tonsillectomy technique groups. The operative time, intra-operative bleeding, post-operative pain, tonsillar fossa healing, return to full diet, return to work and post-operative complications were recorded.

RESULTS

The bipolar radiofrequency group had a shorter mean operative time. The mean intra-operative blood loss during bipolar radiofrequency tonsillectomy was significantly less compared with cold dissection and ultrasonic scalpel tonsillectomy. Pain scores were significantly higher after bipolar electrocautery tonsillectomy. Patients undergoing bipolar electrocautery tonsillectomy required significantly more days to return to full diet and work. The bipolar electrocautery group showed significantly reduced tonsillar fossa healing during the first and second post-operative weeks.

CONCLUSION

In this adult series, bipolar radiofrequency tonsillectomy was superior to ultrasonic, bipolar electrocautery and cold dissection tonsillectomies. This method combines the advantages of 'hot' and 'cold' tonsillectomy.

Antibiotics to reduce post-tonsillectomy morbidity

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008 and previously updated in 2010.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.

OBJECTIVES

To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 20 March 2012.

SELECTION CRITERIA

All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models.

MAIN RESULTS

Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (risk ratio (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of patients with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).

AUTHORS' CONCLUSIONS

The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). The limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence, therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.

Comparison of analgesic effect between gabapentin and diclofenac on post-operative pain in patients undergoing tonsillectomy

Background

Tonsillectomy is a common procedure causing considerable postoperative pain. Postoperative pain intensity of 60 - 70 in the scale of visual analog scale (VAS) has been reported up to 3 - 4 days which could continue until 11 days after the surgery.

Objectives

The current study aimed to compare the analgesic effect of gabapentin and diclofenac on pain after tonsillectomy with the control group.

Patients and Methods

In this double-blind, placebo-controlled clinical trial, 90 patients aged 10-25 years, ASA classes I and II were randomly selected to receive 20 mg/kg oral gabapentin (n = 30), 1.0 mg / kg rectal diclofenac (n = 30) or placebo (n = 30) preoperatively. Pain was evaluated postoperatively on a visual analogue scale at 2, 6, 12 and 24 h. Opioid consumption in the first 24 h after surgery and the side effects were also recorded.

Results

There was no significant difference in terms of age, sex, and time of surgery in the three groups. Patients in the gabapentin and diclofenac groups had significantly lower pain scores at all-time intervals than those in the placebo group. The total meperidine consumed in the gabapentin (14.16 ± 6.97 P = 0.001) and diclofenac (16.66 ± 8.95, P = 0.004) groups was significantly less than that of the placebo (33.4 ± 13.97) group. The frequency of side effects such as vomiting, dizziness, and headache was not significantly different among the groups.

Conclusions

It can be concluded that gabapentin and diclofenac reduced postoperative pain and opioid consumption without obvious side effects.

Nimesulide versus Ibuprofen for Postoperative Tonsillectomy Pain : A Double-Blind, Randomised, Active Comparator-Controlled Clinical Trial

BACKGROUND AND OBJECTIVE

Nonsteroidal anti-inflammatory drugs are effective analgesics but their use during tonsillectomy is controversial because of the risk of postoperative bleeding. The aim of this study was to compare the analgesic efficacy and safety of nimesulide, a preferential cyclo-oxygenase type-2 inhibitor, with ibuprofen in the treatment of pain after tonsillectomy.

STUDY DESIGN

A prospective, double-blind, randomised clinical trial.

PATIENTS AND METHODS

A total of 80 consenting generally healthy patients, aged 14-58 years, undergoing tonsillectomy were randomly assigned to receive either nimesulide 100mg or ibuprofen 800mg orally 60 minutes before surgery. Subsequent doses of the same study medication were administered at 12-hour intervals for the first 7 days, and thereafter when needed. During the first 24 postoperative hours in hospital oxycodone was used for rescue analgesia, and after discharge patients were allowed to use a paracetamol-codeine combination for breakthrough pain. Recovery was recorded up to 3 weeks after surgery.

RESULTS

The need for rescue analgesia during the first 24 hours was similar in the two study groups; 0-7 doses (mean +/- SD 3.3 +/- 1.7 doses) in the nimesulide group and 0-11 doses (3.3 +/- 2.4 doses) in the ibuprofen group. After discharge significant differences were found between the two study groups in favour of the nimesulide-treated patients. Cessation of significant pain while swallowing occurred after 3-19 (10.9 +/- 3.8) days in the nimesulide group versus 7-20 (12.9 +/- 3.3) days in the ibuprofen group (p = 0.041), and return to normal daily activities occurred after 3-21 (10.3 +/- 4.9) days in the nimesulide group versus after 3-19 (12.7 +/- 4.2) days in the ibuprofen group (p = 0.048). At 3 weeks, six of 33 patients in the nimesulide group versus 15 of 37 patients in the ibuprofen group had pain during swallowing (p = 0.049). One patient (3%) in the nimesulide group and five patients (12%) [p = 0.22] in the ibuprofen group needed electrocautery to stop postoperative bleeding.

CONCLUSION

Oral nimesulide was as effective as ibuprofen in pain management after tonsillectomy, and nimesulide improved the recovery after discharge.

Oxycodone and dexamethasone for pain management after tonsillectomy: a placebo-controlled EMG assessed clinical trial

Background

Surface electromyographic (sEMG) study of post-tonsillectomy swallow-evoked muscular reactions was performed in order to evaluate the efficacy and safety of oxycodone and dexamethasone in pain management after tonsillectomy.

Material/Methods

90 randomly chosen operated adults were divided into three groups. Group 1 (n=30) was treated with OxyContin (Oxycodone) injections; Group 2 (n=30) was treated with Dexacort (Dexamethasone), and Group 3 (n=30) was a placebo group. Pain assessment included visual analogue scale (VAS) pain score and the EMG data like the timing, electric amplitude and graphic patterns of muscular activity during deglutition. We investigated masseter, infrahyoid and submental-submandibular muscles. Records from trapezius muscle were used for control. The results were compared with previously established normative database. The patients were tested 24 h after surgery. The sEMG data were compared with VAS pain score with regard to changes in clinical condition of the patients.

Results

Analgesia with oxycodone smoothed the recorded sEMG swallow peaks and increases time of deglutition. Dexamethasone normalized muscular activity in deglutition in cases with edema as detected by the EMG records. Statistically significant difference in muscle reactions was detected between the two Groups and the placebo group.

Conclusions

Application of oxycodone significantly reduces the postoperative pain. Application of dexamethasone after tonsillectomy is advisable because of the reduction of postoperative morbidity while the reduction of the postoperative pain is secondary to the reduction of edema. SEMG might be used as an adjunctive measure of pain behavior via assessment of muscular reactions to pain and to analgesia.

Effect of fibrin-coated collagen fleece (TachoComb) on pain and bleeding after adenotonsillectomy in children

CONCLUSION

Even though the use of TachoComb does not decrease pain after tonsillectomy, it is safe and useful to reduce bleeding after tonsillectomy.

OBJECTIVES

Sealing the post-tonsillectomy wound would be expected to reduce pain and bleeding by decreasing the exposure of the traumatized tissue and sensory nerves. TachoComb is a powerful topical hemostatic agent. The objectives of this study were to evaluate the effect of TachoComb on reduction of pain and bleeding after tonsillectomy.

METHODS

A prospective randomized double-blind study was performed on 120 pediatric patients undergoing adenotonsillectomy. The patients were randomized into two groups: use/non-use of TachoComb. In the study group, each tonsillar bed was covered with a TachoComb strip at the end of operation. No hemostatic agents were used in the control group. After surgery, patients were monitored for pain, bleeding, oral intake, medication administration, activity, and complications using a 10-day diary.

RESULTS

In all, 110 patients returned and filled in the diary. The use of TachoComb did not decrease pain, reduce the use of analgesic drugs or speed recovery to normal everyday life. Post-surgery bleeding was not experienced by any of the TachoComb patients, but occurred in five of the control patients. The result had borderline statistical significance (p < 0.1).

Preoperative lornoxicam for pain prevention after tonsillectomy in adults

STUDY OBJECTIVE

To evaluate the efficacy of preoperative lornoxicam on postoperative pain management following tonsillectomy.

DESIGN

Prospective, randomized, double-blinded, placebo-controlled study.

SETTING

King Fahd University Hospital.

PATIENTS

40 adult, ASA physical status I and II patients scheduled for tonsillectomy.

INTERVENTIONS

Patients were randomly allocated to two groups to receive either intravenous (IV) lornoxicam 16 mg (Group L) or saline as control (Group C) preoperatively. Anesthesia was induced using IV fentanyl and propofol, while endotracheal intubation was facilitated with rocuronium, and maintenance was accomplished using nitrous oxide and sevoflurane.

MEASUREMENTS

Pain scores at rest and on swallowing, intraoperative bleeding, interval until first request for rescue diclofenac suppository, and total diclofenac dose given in the first 12 and 24 hours postoperatively were recorded. The frequency of postoperative complications including bleeding, hypoxia, nausea and vomiting also were observed.

MAIN RESULTS

Pain scores at rest were significantly lower in Group L than Group C at all observation times. Similarly, pain scores on swallowing were lower in Group L during the first 4 postoperative hours. The maximum verbal pain scale (VPS) in the control group was 7 (5.75 - 8 median, interquartile range) and in the lornoxicam group, it was 4 (4 - 5 median, interquartile range) (P < 0.001). The total diclofenac dose during the immediate postoperative 12 hours was significantly lower in Group L than Group C (65 ± 24 mg vs. 20 ± 25 mg, respectively; P < 0.001). No significant differences were noted for intraoperative bleeding. The frequency of postoperative nausea and vomiting was similar in both groups.

CONCLUSION

Preoperative 16 mg lornoxicam was effective for immediate postoperative pain relief after tonsillectomy in adults.

Antibiotics to reduce post-tonsillectomy morbidity

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 2, 2008.Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.

OBJECTIVES

To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to 2009) and EMBASE (1974 to 2009). The date of the last search was 30 October 2009.

SELECTION CRITERIA

All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total (any documented) haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, we generated summary measures using random-effects models.

MAIN RESULTS

Ten trials, comprising a pooled total of 1035 participants, met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were mostly not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (relative risk (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.90, 95% CI 0.56 to 1.44, P = 0.66). With regard to secondary outcomes, antibiotics reduced the proportion of subjects with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).

AUTHORS' CONCLUSIONS

The present systematic review, including meta-analyses for select outcomes, suggests that although individual studies vary in their findings, there is no evidence to support a consistent, clinically important impact of antibiotics in reducing the main morbid outcomes following tonsillectomy (i.e. pain, need for analgesia and secondary haemorrhage rates). Limited benefit apparent with antibiotics may be a result of positive bias introduced by several important methodological shortcomings in the included trials. Based on existing evidence therefore, we would advocate against the routine prescription of antibiotics to patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.

Bipolar radiofrequency tonsillotomy compared with traditional cold dissection tonsillectomy in adults with recurrent tonsillitis

Objective: To compare short- and long-term results of radiofrequency tonsillotomy and traditional cold dissection tonsillectomy in adult patients with recurrent tonsillitis.

Study Design: A randomized clinical trial.

Setting: A tertiary referral university hospital.

Subjects and Methods: Of 62 adults with recurrent tonsillitis, 24 patients were treated with cold dissection tonsillectomy, while radiofrequency tonsillotomy (RF) by use of radiofrequency induced thermotherapy probes was performed in the remaining 38 patients. Duration of surgery, amount of intraoperative bleeding, recovery time, postsurgical pain (measured by use of visual analogue scale on days 1, 3, 5, and 10 after surgery), dysphagia, weight loss, and time of return to normal diet and activity were measured. All the patients were followed for 12 to 24 months for recurrence of tonsillitis episodes.

Results: Comparing the radiofrequency tonsillotomy group to the cold dissection tonsillectomy group, mean duration of surgery was 16.89 versus 45.04 minutes, recovery time was 14.32 minutes versus 17.08 minutes, and amount of intraoperative bleeding was 15 to 20 cc versus 250 to 300 cc, respectively ( P < 0.005). There was no difference between the two groups in the recurrence of tonsillitis episodes after 24 months.

Conclusion: Tonsillotomy with radiofrequency is a simple, rapid, and effective method in adult patients with recurrent tonsillitis.

Antibiotics to reduce post-tonsillectomy morbidity

BACKGROUND

Tonsillectomy continues to be one of the most common surgical procedures performed in children and adults. Despite improvements in surgical and anaesthetic techniques, postoperative morbidity, mainly in the form of pain, remains a significant clinical problem. Postoperative bacterial infection of the tonsillar fossa has been proposed as an important factor causing pain and associated morbidity, and some studies have found a reduction in morbid outcomes following the administration of perioperative antibiotics.

OBJECTIVES

To determine whether perioperative antibiotics reduce pain and other morbid outcomes following tonsillectomy.

SEARCH STRATEGY

Cochrane ENT Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2007), MEDLINE (1950 to 2007) and EMBASE (1974 to 2007) were searched. The date of the last search was March 2007.

SELECTION CRITERIA

All randomised controlled trials examining the impact of perioperative administration of systemic antibiotics on post-tonsillectomy morbidity in children or adults.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data. Primary outcomes were pain, consumption of analgesia and secondary haemorrhage (defined as significant if patient re-admitted, transfused blood products or returned to theatre, and total if any documented haemorrhage). Secondary outcomes were fever, time taken to resume normal diet and activities and adverse events. Where possible, summary measures were generated using random-effects models.

MAIN RESULTS

Nine trials met the eligibility criteria. Most did not find a significant reduction in pain with antibiotics. Similarly, antibiotics were not shown to be effective in reducing the need for analgesics. Antibiotics were not associated with a reduction in significant secondary haemorrhage rates (Relative Risk (RR) 0.49, 95% CI 0.08 to 3.11, P = 0.45) or total secondary haemorrhage rates (RR 0.92, 95% CI 0.45 to 1.87, P = 0.81). With regard to secondary outcomes, antibiotics reduced the proportion of subjects with fever (RR 0.63, 95% CI 0.46 to 0.85, P = 0.002).

AUTHORS' CONCLUSIONS

The present review suggests that there is little or no evidence that antibiotics reduce the main morbid outcomes following tonsillectomy (i.e. pain, the need for analgesia or secondary haemorrhage rates). They do however appear to reduce fever. Some important methodological shortcomings exist in the included trials which are likely to have produced bias favouring antibiotics. We therefore advocate caution when prescribing antibiotics routinely to all patients undergoing tonsillectomy. Whether a subgroup of patients who might benefit from selective administration of antibiotics exists is unknown and needs to be explored in future trials.

Intravenous paracetamol is highly effective in pain treatment after tonsillectomy in adults

Tonsillectomy in adults is associated with significant postoperative pain. Intravenous paracetamol injection (Perfalgan) is marketed for the management of acute pain. This prospective placebo-controlled study was performed to evaluate the analgesic efficacy and safety of intravenous paracetamol in 76 adult patients undergoing elective standard bipolar diathermy tonsillectomy. After tonsillectomy was performed under general anesthesia, the patients were randomized to receive either intravenous paracetamol 1 g (Perfalgan) (n = 38) or 0.9% normal saline as a placebo (n = 38) at 6-h intervals. No other analgesic medication was permitted for postoperative pain during the study. Need for rescue analgesic during the first 24 h after surgery as well as all adverse events were recorded. The intravenous paracetamol group differed significantly from the placebo group regarding pain relief and median time to pethidine rescue. Intravenous paracetamol significantly reduced pethidine consumption over the 24-h period. The worst pain after surgery was also more severe in the placebo group than that in the paracetamol group. There was no significant difference between groups in the incidence of adverse events. Intravenous paracetamol administered regularly in adult patients with moderate to severe pain after tonsillectomy provided rapid and effective analgesia and was well tolerated.

Pain treatment and recovery after endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Early recovery and pain management after endoscopic sinus surgery (ESS) are largely unexplored regardless of the large number of ESSs performed by otorhinolaryngologists. In the present study, we evaluated whether scheduled administration of acetaminophen (paracetamol) for pain management after ESS would allow faster recovery to normal daily activities compared with acetaminophen administered on an as needed basis.

STUDY DESIGN

Open, prospective, randomized, controlled clinical trial with two parallel groups.

METHODS

There were 78 patients who were undergoing ESS and were randomized into two groups. The "scheduled" group (n = 38) was instructed to take two acetaminophen 665 mg modified-release tablets three times a day during the first five postoperative days, whereas the "as needed" group (n = 40) was given instructions to use acetaminophen 665 mg tablets only on an as needed basis. Patients filled in a questionnaire at the follow-up visits on the 7th and 30th postoperative days. The main outcome measures were return to normal daily activities (primary endpoint) and pain during the first week after surgery and patients' satisfaction with pain management (secondary endpoints).

RESULTS

Patients returned to their normal daily activities in 8.8 (SD 4.8) days in the "scheduled" group versus in 10.3 (SD 7.0) days in the "as needed" group (mean difference 1.5; 95% CI of the difference -1.3 to 4.2; P = .29). In the "scheduled" group, the mean of worst pain was 3.4 (2.9) compared with 5.2 (3.0) in the "as needed" group on an 11-point scale (mean difference 1.7; 95% CI of the difference 0.4-5.2; P = .019). The patients in both groups were equally satisfied with pain management.

CONCLUSIONS

The present study suggests that patients recover in 9 to 10 days after ESS when provided with appropriate pain management. Our data indicate that by prescribing scheduled acetaminophen, postoperative pain after ESS can be controlled effectively without the need for opioid analgesics.

Acetaminophen is Highly Effective in Pain Treatment After Endoscopic Sinus Surgery

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is increasingly performed by otorhinolaryngologists. However, the early recovery and pain management after ESS is still largely unexplored. In the present study, we have evaluated the incidence and severity of pain and the efficacy and safety of acetaminophen (paracetamol) for pain management in patients undergoing ESS.

STUDY DESIGN

The authors conducted a prospective, double-blind, placebo-controlled clinical trial.

METHODS

Seventy-four patients with ESS were randomized to receive either 1 g intravenous acetaminophen (Perfalgan) (n = 36) or 0.9% normal saline as a placebo (n = 38) after ESS was performed under local anesthesia. No other analgesic medication was permitted during the study. Need for rescue analgesic during the first 4 hours after surgery as well as all adverse events were recorded.

RESULTS

Most patients, 27 of 38 (71%), in the placebo group needed rescue analgesics but significantly fewer patients in the acetaminophen group required rescue analgesia, i.e., only nine of 36 (25%) patients needed oxycodone. The worst pain after surgery was also more severe in the placebo group than that in the acetaminophen group. There was no significant difference between groups in the incidence of adverse events. The most common adverse events were vomiting, nausea, and headache.

CONCLUSIONS

ESS is associated with significant postoperative pain. Acetaminophen provides adequate pain relief in most patients who have undergone ESS. However, the analgesic efficacy of acetaminophen alone is insufficient in some patients, and hence all patients with ESS must be followed closely to identify those patients in need of more efficient analgesia during the early phase of recovery.

Fibrin sealant reduces pain after tonsillectomy: prospective randomized study

OBJECTIVES

Postsurgical pain in adults following tonsillectomy with fibrin sealant or electrocoagulation was assessed by surface electromyography (sEMG), a dysphagia severity rating scale (DSRS), and a visual analog scale (VAS) pain

METHODS

For group 1 (n = 40), hemostasis was achieved by fibrin sealant spraying to the tonsillar fossae. For group 2 (n = 40), hemostasis was achieved by bipolar or needle point electrocautery. The timing of single swallowing and continuous drinking and the mean electrical activity of the masseter, infrahyoid, and submental-submandibular muscles were compared with a normative database during 30 days and with DSRS and VAS scores.

RESULTS

Electrical activity of the masseter and infrahyoid muscles was significantly higher in both groups in comparison with the normative database (p < .05 to p < .005), whereas timing was less affected. The combined sEMG, DSRS, and VAS assessment showed that tonsillectomy ended with sealant causes less pain than electrocoagulation (p < .05). The DSRS score data were in strong positive correlation with the sEMG records, whereas the VAS pain score was less informative.

CONCLUSIONS

The combined sEMG and pain score data indicate that the electrocautery hemostatic technique is more painful and traumatic than the sealant technique. Surface electromyography of swallowing is a simple, reliable evaluation method for postsurgical odynophagia complaints and might be used as an objective tool for pain assessment.

The effect of gabapentin on post-operative pain following tonsillectomy in adults

BACKGROUND

The aim of the present study was to investigate whether a combination of rofecoxib and gabapentin could improve pain relief and reduce opioid requirements, compared with rofecoxib alone, during the first 5 days after tonsillectomy.

METHODS

In a randomized, double-blind, placebo-controlled study, 49 patients received gabapentin 1200 mg pre-operatively, followed by gabapentin 2 x 600 mg on the day of operation and gabapentin 3 x 600 mg for the next 5 days, or placebo. Both groups were given rofecoxib 50 mg daily. In the post-operative care unit, intravenous morphine was administered in doses of 2.5 mg on request. From 4 h to 5 days post-operatively, ketobemidone was offered as escape drug. Pain at rest and during swallowing, and side-effects, were assessed using a four-point verbal rating scale.

RESULTS

As a result of the global withdrawal of rofecoxib, the study had to be terminated prematurely. This report comprises the results from 22 patients in the gabapentin group and 27 patients in the placebo group. Gabapentin reduced ketobemidone requirements during the first 24 h post-operatively [4.5 mg (standard deviation, 3.0 mg) in the placebo group vs. 2.0 mg (standard deviation, 2.0 mg) in the gabapentin group; P < 0.003]. Gabapentin induced more dizziness (P < 0.002), gait disturbance (P < 0.02) and vomiting (P < 0.05) during days 0-5 than placebo. No other statistically significant differences were observed.

CONCLUSION

Gabapentin reduced opioid requirements in the first 24 h after tonsillectomy. The benefits of the reduced opioid intake may be overshadowed by the drawbacks of side-effects.

The use of perioperative antibiotics in tonsillectomy: does it decrease morbidity?

OBJECTIVE

To assess the efficacy of perioperative antibiotics in decreasing post-operative morbidity among patients undergoing tonsillectomy or adenotonsillectomy.

DESIGN

Meta-analysis based on a structured search of the literature, using MEDLINE and the Cochrane database.

SUBJECTS

Only articles, which included both treatment and control groups, were included in the final analysis. Studies were limited to ones that involved human subjects, including both children and adults. Studies using steroids and topical antibiotics were excluded.

OUTCOMES

Articles were abstracted for patient factors, elements of study design, methods of patient assignment to treatment and control groups, and clinical outcomes. The primary outcome, time required for return to normal oral intake, was analyzed in the final meta-analysis.

METHODS

Four hundred and twenty-eight articles were initially identified. There were 23 potentially appropriate articles. Of these, 18 were able to be located in full text form and in English. Seven of these studies directly studied the efficacy of perioperative antibiotics (versus no antibiotics) in decreasing post-operative morbidity. Four studies had sufficient information to calculate effects estimates (xi) and standard deviations (Si) for the primary outcome. Three studies either did not report the outcome of interest or did not report a measure of stability (e.g. p-value or confidence interval). The data available from the first four studies were combined in a quantitative meta-analysis. Statistical analyses were performed using STATA for Windows software.

RESULTS

The pooled estimate indicated that the antibiotic group returned to normal oral intake, on average, 1 day sooner than the controls. This difference was found to be statistically significant with a 95% confidence interval of 0.5-1.6 days. An additional assessment of three qualitative reports also suggested the use of perioperative antibiotics for adenotonsillectomy was associated with less post-operative pain. However, studies varied in terms of study quality, sample size, outcome examined, measure used and antibiotic administered. Definitive conclusions regarding the effect of perioperative antibiotics on other outcomes including bleeding, halitosis, fever, activity level and nausea and vomiting could not be drawn due to the small numbers of studies.

CONCLUSIONS

In this meta-analysis, the use of perioperative antibiotics in patients who have had tonsillectomy or adenotonsillectomy appears to be associated with a 1-day reduction in the time required for return to normal oral intake. For other potentially important outcomes, such as post operative pain or bleeding, sufficient data were not available to make any definitive conclusions regarding the effect of perioperative antibiotics.

Ketoprofen and tramadol for analgesia during early recovery after tonsillectomy in children

BACKGROUND

Pain following tonsillectomy is often intense. Nonsteroidal anti-inflammatory drugs and opioids are effective, but both can cause adverse effects. Tramadol may be a viable alternative for post-tonsillectomy pain. This study was designed to compare the analgesic effects of ketoprofen and tramadol during the early recovery period after tonsillectomy.

METHODS

Forty-five ASA class I children (9-15 years) were randomized to receive either saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)) after induction of anesthesia. Upon completion of surgery, the study treatment was continued as a 6 h intravenous (i.v.) infusion of another dose of saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)). Postoperatively, each patient received rescue analgesia with patient-controlled analgesia (PCA) device programmed to deliver 0.5 microg.kg(-1) bolus doses of fentanyl. Postoperative pain was assessed using Visual Analog Scale (VAS) during swallowing. Intraoperative blood loss was measured.

RESULTS

The total number of requests of PCA-fentanyl was significantly less in ketoprofen group compared with tramadol and placebo groups (P = 0.035 and P = 0.049, respectively, in pairwise comparisons) and the VAS scores for pain were significantly lower in ketoprofen group compared with tramadol (P = 0.044) or placebo groups (P = 0.018) during the first six postoperative hours. Measured intraoperative blood loss was greater in ketoprofen-treated patients than in those receiving placebo (P = 0.029).

CONCLUSION

A dose of 4 mg.kg(-1) of i.v. ketoprofen provided good pain relief with moderate supplemental PCA-fentanyl requirements during the first six postoperative hours after tonsillectomy in children whereas the effects of 2 mg.kg(-1) of i.v. tramadol did not differ from those of placebo.

Local bupivacaine-epinephrine infiltration combined with general anesthesia for adult tonsillectomy

CONCLUSION

Use of a solution of bupivacaine (5 mg/ml)-epinephrine (5 microg/ml) (BE) is beneficial in reducing intraoperative bleeding and decreasing the operation time in adult (adeno)tonsillectomy patients.

OBJECTIVE

Pain and intra- and postoperative bleeding are problems associated with tonsillectomy/adenotonsillectomy. In order to make tonsillectomy/adenotonsillectomy better suited to outpatient surgery, solutions to these problems should be found. One possibility may be the combination of local and general anesthesia. The aim of this study was to find out if such a combination is beneficial in tonsillectomy/adenotonsillectomy.

MATERIAL AND METHODS

We performed a prospective, randomized, double-blind, controlled study on 64 adult (adeno)tonsillectomy patients to investigate the possible benefits of infiltrating the peritonsillar space with a BE solution.

RESULTS

In the recovery room, the BE group experienced less pain than a control group infiltrated with saline; subsequently there was no significant difference between the groups concerning pain. The average volume of intraoperative bleeding and the operation time were significantly smaller in the BE group. Postoperative bleeding from the tonsillar fossae occurred in 19% (6/31) of the patients in the BE group and in 18% (6/33) in the saline group.

Celecoxib and ketoprofen for pain management during tonsillectomy: a placebo-controlled clinical trial

OBJECTIVE

To evaluate the efficacy and safety of celecoxib and ketoprofen in pain management during tonsillectomy in 120 patients.

STUDY DESIGN AND SETTING

The study was randomized, double-blind, and placebo-controlled with parallel groups. Sixty minutes before anesthesia induction and 12 hours after, the patients received a 200-mg celecoxib, a 100-mg ketoprofen, or a placebo capsule. After discharge, patients were prescribed either celecoxib or ketoprofen capsules to be taken every 12 hours.

RESULTS

During the first 24 hours, the need for rescue analgesic was less in the ketoprofen-group (5 [1-9]) doses (median [range]) than in the placebo-group (6 [1-13]) ( P = 0.021), but similar to the celecoxib-group (5 [2-14]). After discharge, the cessation of pain during eating occurred earlier in the celecoxib-treated patients, after 10 (1-17) days, than in the ketoprofen-treated patients, after 12 (1-21) days, ( P = 0.008). One celecoxib-treated patient and 6 ketoprofen-treated patients ( P = 0.013) needed electrocautery to stop postoperative bleeding.

CONCLUSION

Ketoprofen provided a better initial analgesic efficacy but after discharge the recovery with celecoxib was faster and the incidence of secondary hemorrhages was lower.

SIGNIFICANCE

Celecoxib seems to be more effective and safe than ketoprofen for pain management after discharge in patients with tonsillectomy.

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a major public health problem in the US that afflicts at least 2% to 4% of middle-aged Americans and incurs an estimated annual cost of 3.4 billion dollars. At Stanford, we utilize a multispecialty team approach combining the expertise of sleep medicine specialists (adult and pediatric), maxillofacial and ear, nose, and throat surgeons, and orthodontists to determine the most appropriate therapy for complicated OSA patients. The major treatment modality for children with OSA is tonsillectomy and adenoidectomy with or without radiofrequency treatment of the nasal inferior turbinate. Children with craniofacial anomalies resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or more invasive maxillary/mandibular surgery. Continuous positive airway pressure (PAP) therapy is used in children with OSA who are not surgical candidates or have failed surgery. As a last resort, tracheotomy may be used in patients with persistent or severe OSA who do not respond to other measures. The cornerstone of treatment in adults utilizes PAP: continuous PAP, bilevel PAP, or auto PAP. Treatment of nasal obstruction, appropriate titration, attention to mask-fit issues, desensitization for claustrophobia, use of heated humidification for nasal dryness and nasal pain with continuous PAP, patient education, regular follow-up, use of compliance software (in selected individuals), and referral to support groups (AWAKE) are measures that can improve patient compliance. Adjunctive treatment modalities include lifestyle/behavioral/pharmacologic measures. Oral appliances can be used in patients with symptomatic mild sleep apnea or upper airway resistance syndrome. Patients who are unwilling or unable to tolerate continuous PAP or who have obvious upper airway obstruction may benefit from surgery. Surgical success depends on appropriate patient selection, the procedure performed, and the experience of the surgeon. Phase I surgeries have a success rate of 50% to 60%, whereas phase II surgeries have a success rate greater than 90%.

[Inpatient treatment of tonsillectomy from the patient's point of view]

BACKGROUND

Hospitalization after tonsillectomy for more than 24 h is still controversial. In order to obtain the patient's point of view, we designed a questionnaire for all patients undergoing tonsillectomy.

METHODS AND RESULTS

From January 2002, we asked all patients admitted for elective tonsillectomy to fill out an anonymous questionnaire on their preferences for the duration of hospitalization after surgery. The majority of patients (79.6%) returning the questionnaire supported a hospital stay of at least 4 days after surgery. Options for a shorter stay of only 24 h or tonsillectomy in day-surgery without overnight stay were declined by all patients.

CONCLUSION

We found that most patients preferred to remain in hospital for about 4 days postoperatively because they felt that they would have better access to effective analgesia. Another reason involved the increased risk for haemorrhage during the first few days after tonsillectomy.

Current status of pre-emptive analgesia

PURPOSE OF REVIEW

The controversy over preemptive analgesia continues unabated, with studies both supporting and refuting its efficacy. The timing of an analgesic intervention and presence of a placebo control may have significant impact on the interpretation of results and may have led to the premature conclusion that preemptive analgesia is of limited clinical utility. A review of the recent literature using strict definitions of preemptive and preventive analgesia is required in order to clarify the broader issue of the benefits of perioperative analgesia.

RECENT FINDINGS

A total of 27 studies, published from April 2001 to April 2002, were found to evaluate preemptive (n = 12) or preventive analgesia (n = 15). Evidence for a benefit of preventive analgesia was strong, with 60% of studies finding reduced pain or analgesic consumption beyond the clinical duration of action of the analgesic intervention. Evidence for a benefit of preemptive analgesia was equivocal, with 41.7% of studies demonstrating that preincisional treatment reduces pain or analgesic consumption to a greater extent than does postincisional treatment.

SUMMARY

Studies that used a preventive design had a greater likelihood of finding a beneficial effect. The application of preventive perioperative analgesia (not necessarily preincisional) is associated with a significant reduction in pain beyond the clinical duration of action of the analgesic agent, in particular for the N-methyl-D-aspartate antagonists. The classical definition of preemptive analgesia should be abandoned in favor of preventive analgesia. This will broaden the scope of inquiry from a narrow focus on preincisional versus postincisional interventions to one that aims to minimize postoperative pain and analgesic requirements by reducing peripheral and central sensitization arising from noxious preoperative, intraoperative and postoperative inputs.