Tonsillectomy care for the pediatrician

Effect and safety of perioperative ibuprofen administration in pediatric tonsillectomy: A systematic review and meta-analysis

OBJECTIVES

This study aimed to evaluate the safety and efficacy of perioperative ibuprofen administration by conducting a meta-analysis of pertinent literature.

METHODS

We conducted a comprehensive review of studies sourced from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases. The studies covered the period from database inception to June 2024. A perioperative ibuprofen administration group was compared to a control group administered either saline, acetaminophen, paracetamol, or opioids. The primary outcome was post-tonsillectomy bleeding that was categorized into overall bleeding and further classified as type 1 (observed at home or evaluated in the emergency department without additional intervention), type 2 (necessitating readmission for observation), and type 3 (requiring a return to the operating room for hemorrhage control). Morbidity incidence rates for postoperative nausea and vomiting were also assessed. The secondary outcomes assessed were postoperative pain management and the frequency of analgesic drug usage. Postoperative pain management was assessed from the incidence of emergency department visits or nurses' calls for pain independent of the presence or absence of dehydration.

RESULTS

Twenty-two studies with 27,149 patients were included and reviewed for this meta-analysis. Post-tonsillectomy bleeding (OR = 0.9954, 95 % CI [0.8800; 1.1260], I2 = 0.0 %) was not significantly higher in the ibuprofen administration group compared to the control group. In subgroup analysis of post-tonsillectomy bleeding severity, ibuprofen caused clinically insignificant type 1 post-tonsillectomy bleeding that did not require intervention (OR = 1.1310 [0.7398; 1.7289]). Clinically significant bleeding requiring hospital admission (type 2) or surgical control (type 3) was not observed. Administration of ibuprofen has demonstrated efficacy in reducing the need for analgesic drugs (OR = 0.4734, 95 % CI [0.2840; 0.7893]; I2 = 19.8 %) and is associated with a significant decrease in the incidence of postoperative nausea and vomiting (OR = 0.4886, 95 % CI [0.3156; 0.7562], I2 = 34.3 %).

CONCLUSION

This study demonstrated that administration of ibuprofen for pediatric tonsillectomy did not increase the incidence of clinically significant postoperative bleeding. Ibuprofen administration decreased the incidence and severity of postoperative pain, nausea, and vomiting.

Postoperative Outcomes Following KTP-532 LASER Versus Coblation Assisted Paediatric Tonsillectomy

Aim: The aim of the study was to compare postoperative outcomes such as pain, healing of tonsillar fossa and return to normal diet following KTP-532 LASER versus Coblation assisted tonsillectomy. Methods: A prospective randomised clinical study was conducted over a 24-month period at a tertiary referral centre. Children aged 3-16 years underwent KTP-532 LASER assisted versus Coblation assisted tonsillectomy. A total of 60 children were randomly allocated into two groups-Group A underwent KTP-532 LASER assisted tonsillectomy, and Group B underwent Coblation assisted tonsillectomy (n = 30 in each). Postoperative pain and tonsillar fossa slough formation was evaluated on postoperative day 0, 1, 7, 14 and 28, and average duration taken to resume regular diet. Result: There was no statistically significant difference in postoperative pain between the two groups. There was significantly lesser slough formation in Group B on 1st postoperative day (p < 0.000), 7th postoperative day (p < 0.014), and 14th postoperative day (p < 0.010) when compared with Group A. Complete mucosalisation was achieved significantly earlier in Group B when compared to Group A (p < 0.01). Average duration for resumption of normal diet was 13.5 days for Group A and 12.6 days for Group B postoperatively, which was statistically insignificant (p < 0.830). Conclusion: There was no significant difference in postoperative pain between the two groups. Postoperative slough formation was significantly lesser and tonsillar fossa mucosalisation was faster in Group B. There was no statistical difference in time taken to resume normal diet.

Efficacy of Sucralfate in Alleviating Post Tonsillectomy Symptoms and Morbidity: A Comparative Randomized Interventional Study

Pain following tonsillectomy still remains the main concern of topic and it occurs along with sever ear pain and trismus until and unless the exposed and inflamed mucosa gets covered with the regenerated mucosa. To study the efficacy of sucralfate in alleviating postoperative pain and morbidity following tonsillectomy. Subjects included in our study were patients which were fulfilling criteria for tonsillectomy and were admitted under the Department of Otorhinolaryngology, SMS Medical College and Hospital, Jaipur from 1st July 2019 to 31st March 2020. 64 patients were evaluated and were randomly allocated into study and control group based on the administration of topical sucralfate. 64 patients who were admitted for tonsillectomy under the Department of Otorhinolaryngology, SMS Medical College and Hospital, Jaipur from 1st July 2019 to 31st March 2020 were included in study. Patients were evaluated and were randomly allocated into study and control group based on the administration of topical sucralfate. The incidence of throat pain and otalgia showed significant difference among both the group following postoperative day 2 onwards. On postoperative day 2, significant difference in trismus was also found. Effective alleviation of pain not only improves early dietary intake of the patients but also allays fear of apprehensive parents.

Association of perioperative ibuprofen exposure with post-tonsillectomy bleeding requiring operative management

INTRODUCTION

Pediatric tonsillectomy is one of the most common surgical procedures performed in the United States. The safety of ibuprofen use after surgery is debated given concern for increased bleeding. The primary objective of this study was to compare the rate of post-tonsillectomy hemorrhage requiring operative management in patients who received ibuprofen perioperatively vs. patients who did not.

METHODS

Retrospective cohort study of patients 0-18 years old who underwent tonsillectomy with or without adenoidectomy (T&A) with recorded inpatient medication administration data at a single tertiary care institution from 1/2005-1/2019. The association between perioperative medication administration and return to operating room (OR) for control was evaluated using multivariable logistic regression adjusted for patient demographics and operative indication. Secondary outcomes evaluated included the time to operative bleed when it occurred.

RESULTS

A total of 4098 patients with a median age of 6 years old (IQR 4-10) underwent T&A over the study period. The overall rate of post-tonsillectomy hemorrhage requiring OR was 3.37% (n = 138/4098). After adjustment for confounders, the odds of bleeding requiring OR did not differ significantly between the ibuprofen (OR 1.16, 95% CI (0.76, 1.74), 3.55%, n = 41/1,156, p = 0.47) and non-ibuprofen groups (3.30%, n = 97/2942). The median time to bleeding requiring OR was postoperative day 6.5 (IQR6-8) in the ibuprofen group and day 6 (IQR 3-8) in the non-ibuprofen group.

CONCLUSIONS

No difference in post-tonsillectomy hemorrhage requiring OR was observed between patients receiving perioperative ibuprofen versus those patients not receiving this medication. Additional research is required to definitively determine a safe dose and interval for ibuprofen administration following tonsillectomy.

Recovery After Adenotonsillectomy-Do Steroids Help? Outcomes From a Randomized Controlled Trial

OBJECTIVES

The primary objective was to compare pain control following adenotonsillectomy (AT) in children with and without a single postoperative dose of oral dexamethasone in addition to standard analgesic medication. The secondary objective was to compare changes in caregiver-reported snoring, return to normal diet and baseline function, and the number of phone calls and emergency department (ED) visits.

STUDY DESIGN

Prospective randomized controlled trial.

SETTING

Tertiary care university hospital.

METHODS

Children aged 3 to 10 years with sleep-disordered breathing who were scheduled to undergo AT were randomized to receive standard analgesia with or without dexamethasone (0.6 mg/kg) administered on the third postoperative day. Standard analgesia was defined as alternating weight-based doses of ibuprofen and acetaminophen. A nurse practitioner blinded to the study condition performed telephone surveys postoperatively, and the electronic medical record was reviewed.

RESULTS

Enrollment comprised 149 children, of whom 119 were included. When compared with the control group (n = 61, 51%), children who received dexamethasone (n = 58, 49%) had a greater decrease in reported pain score on day 4 (mean ± SD, 2.5 ± 3.1 vs 1.1 ± 3.5, P < .001). Additionally, steroid use was associated with fewer caregiver phone calls (18 [29.5%] vs 6 [10%]) and ED visits (6 [10%] vs 1 [2%]).

CONCLUSION

A single dose of dexamethasone administered on day 3 after adenotonsillectomy significantly improved pain control. There were fewer phone calls and ED visits in the steroid arm. These results support the use of oral steroids as an adjunct for postoperative pain control in children undergoing AT.

Efficacy of pillar suture for post-tonsillectomy morbidity in children: a meta-analysis

Introduction

Several surgical techniques have been used during tonsillectomy to reduce complications.

Objectives

To assess the effects of pillar suture in conjunction with tonsillectomy as compared to tonsillectomy without suture in children.

Methods

Two authors independently searched five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database) for studies published as recent as December 2018. Of the included studies, we compared tonsillectomy and pillar suture in combination (suture groups) with tonsillectomy alone,without suture, (control group). Postoperative pain intensity and other morbidities (e.g., postoperative bleeding, palatal hematoma, discomfort, and pillar edema) were measured during the postoperative period.

Results

Postoperative bleeding [primary (OR = 0.47 [0.27; 0.81]) and secondary (OR = 0.14 [0.02; 0.78]) were significantly decreased in the pillar suture group compared to the control group. There were no significant differences between the two groups in postoperative pain at day 7 (SMD = −0.39 [−0.79; 0.00]), palatal hematoma (OR = 5.00 [0.22; 112.88]), palatal discomfort sensation (OR = 2.62 [0.60; 11.46]), site infection (OR = 5.27 [0.24; 113.35]), and velopharyngeal insufficiency (OR = 2.82 [0.11; 74.51]). By contrast, pillar edema (OR = 9.55 [4.29; 21.29]) was significantly increased in the pillar suture group compared to the control group.

Conclusions

Pillar suture combined with tonsillectomy may reduce postoperative bleeding incidence despite increasing pillar edema in pediatric tonsillectomy. Postoperative pain-relief, palatal hematoma, palatal discomfort sensation, site infection, and velopharyngeal insufficiency were not significantly altered compared to tonsillectomy alone. However, further studies are needed to corroborate the results of this study.

Wound healing after tonsillectomy - a review of the literature

OBJECTIVE

To summarise the available literature related to wound healing post tonsillectomy, including the stages of healing, experimental models for assessing healing (in animals and humans) and the various factors that affect wound healing.

METHODS

A search of the English literature was conducted using the Ovid Medline database, with the search terms 'tonsillectomy' or 'tonsil' and 'wound healing'. Thirty-one articles that objectively assessed tonsillectomy wound healing were included for analysis.

RESULTS

The majority of assessments in humans investigating tonsillectomy wound healing involve serial direct clinical examinations of the oral cavity. Many patient and surgical factors have been shown to affect wound healing after tonsillectomy. There is some research to suggest that the administration of adjunctive treatment in the post-operative period may be beneficial to tonsillectomy wound healing.

CONCLUSION

Wound healing post tonsillectomy has been poorly researched. Having a better understanding of the process of wound healing would allow surgeons to potentially prevent, anticipate and manage complications from the surgery that arise as part of the healing process.

Postoperative Tonsillectomy Hemorrhage

Post-tonsillectomy hemorrhage represents a potentially life-threatening condition that occurs in up to 5% of pediatric patients. Minor bleeding often precedes severe hemorrhage. Patients with minor or self-resolving bleeding should be observed in the emergency department or admitted for monitoring. Patients with severe bleeding should be immediately assessed for airway and hemodynamic stability. Management of severe bleeding includes immediate surgical consultation or initiation of the transfer process to a center with surgical capabilities, direct pressure to the site of hemorrhage with or without the additional of a hemostatic agent, possible rapid sequence intubation, and management of hemodynamic instability with volume resuscitation.

Design and validation of key text messages (Tonsil-Text-To-Me) to improve parent and child perioperative tonsillectomy experience: A modified Delphi study

OBJECTIVE

Parents can struggle while providing perioperative tonsillectomy care for their children at home. Short message service (SMS) technology is an accessible and direct modality to communicate timely, evidence-based recommendations to parents across the perioperative period. This study focused on validating a SMS protocol, Tonsil-Text-To-Me (TTTM), for parents of children undergoing tonsillectomy.

METHODS

This study used a modified Delphi expert consensus method. Participants were an international sample of 27 clinicians/researchers. Participants rated level of agreement with recommendations across seven perioperative domains, derived systematically from scientific and lay literature. A priori consensus analysis was conducted using threshold criterion. A multidisciplinary team of local clinicians were also individually interviewed to consolidate text messages and implement recurrent suggestions.

RESULTS

In the modified Delphi panel, 30 statements reached threshold agreement (>3.0 of 4.0); recommendations surrounding diet (3.87) and hygiene (3.83) had the highest level of consensus, while recommendations regarding activity (3.42) and non-pharmacologic pain management (3.55) had the lowest consensus. The 30 statements reconfigured into 12 concise text messages. After further interviews with local clinicians, 14 final text messages were included in the SMS protocol to be sent two weeks preoperatively to one week postoperatively.

CONCLUSION

This study illustrates the development of TTTM which is designed to deliver key sequential text messages at the optimal time during the perioperative setting to parents caring for their children who are undergoing tonsillectomy.

Experience is more important than technology in paediatric post-tonsillectomy bleeding

BACKGROUND

Paediatric tonsillectomy is a common procedure and one of the first skills acquired by surgical trainees. Post-tonsillectomy bleeding is one of the most significant complications. This study examined post-tonsillectomy bleed rates associated with technology and level of surgical experience.

METHODS

Data were collected on all tonsillectomies performed by surgical consultants (n = 6) and trainees (n = 10) at affiliated hospitals over a nine-month period. Hospital records were audited for post-tonsillectomy bleeding re-admissions and returns to the operating theatre.

RESULTS

A total of 1396 tonsillectomies were performed (279 by trainees, 1117 by consultant surgeons). Primary post-tonsillectomy bleed rates were equivalent between trainees and consultants. Secondary bleed rates were significantly greater for trainees (10.0 per cent) compared to consultants (3.3 per cent), as were return to operating theatre rates (2.5 per cent vs 0.7 per cent). Amongst consultants, technology used was not associated with differences in secondary post-tonsillectomy bleeding and returns to the operating theatre.

CONCLUSION

Our data suggest that experience of the surgeon may have greater bearing on post-tonsillectomy bleed rates than the technology used.

Effectiveness of hyaluronic acid in post-tonsillectomy pain relief and wound healing: a prospective, double-blind, controlled clinical study

OBJECTIVES

To find the effectiveness of hyaluronic acid in post-tonsillectomy pain relief and wound healing.

METHODS

Fifty patients were included in this prospective, double-blind, controlled clinical study (20 males, 30 females mean age of 13.56 years). Hyaluronic acid was applied to one side and the other side was used as a control during tonsillectomy. Therefore, the same patient evaluated and scored the post-tonsillectomy pain, excluding individual bias.

RESULTS

Results indicated that patients had significantly lower pain scores for hyaluronic acid treated side (p<0.001). At the end of two weeks follow-up period, the wound in the hyaluronic acid side was almost completely healed, indicating that the healing was faster with hyaluronic acid compared to control side (p<0.001).

CONCLUSION

Hyaluronic acid could be recommended as an effective treatment for the management of post-tonsillectomy pain and wound healing.

Nursing process in post tonsillectomy pain diagnosis: a systematic review

Objective:

Tonsillectomy is the most common surgery in the field of ENT. Pain is the most common post tonsillectomy complaint. Considering the importance of nursing cares in relieving post-surgery pain in general and post-tonsillectomy pain in particular, this study is conducted with the aim of presenting nursing process in post tonsillectomy pain diagnosis for decreasing loss of appropriate opportunities in nursing cares and achieving appropriate results in taking care of the patients.

Methods:

This study is a targeted systematic review focusing on “effective nursing measures in relieving children’s post tonsillectomy pain”. The main stages of searching strategy included searching in electronic sources of Latin databases; Pub Med, Science Direct, and EMBASE and Persian databases; SID, Iran medex, ISC to find published articles from 2009 to 2014. In the end, final synthesis was done on eight articles in English.

Findings:

Effective nursing measurements for relieving post tonsillectomy pain include: decreasing children’s anxiety through children and their families’ psychological preparation by nurses and other caregivers, using cold compress to reduce neck and jaw pain, presenting distraction techniques, offering fluids and cold foods immediately in the period after surgery, creating a comfortable environment for the children, avoiding too much of talking and adequate sleep.

Conclusion:

It is recommended to the nursing managers and nurses to perform cares achieved from this systematic review to achieve appropriate results in relieving post tonsillectomy pain.

Efficacy of sucralfate for the treatment of post-tonsillectomy symptoms

Pain after tonsillectomy remains the main issue of postoperative morbidity and the search for an effective post-tonsillectomy analgesic is of increasing relevance. The aim of this study was to evaluate the effectiveness of topical sucralfate during an early post-tonsillectomy period. Fifty patients of both genders from 6 to 58 years submitted to tonsillectomy or adenotonsillectomy were randomly included into either a sucralfate treatment group (N = 25) or into a control group (N = 25). Patients of the sucralfate group received topical sucralfate four times a day for 7 days. No topical treatment was applied to patients of the control group. A systemic analgesic was standardized. Post-tonsillectomy symptoms, including throat pain, odynophagia and otalgia, were evaluated during the period of seven postoperative days. Secondary outcomes were analgesic use, well being in general, return to regular daily activities, secondary hemorrhage and side effects of sucralfate. This study revealed that during the period of the second to seventh postoperative days average throat pain scores of the sucralfate using patients were significantly lower than those of the control group patients (p < 0.05); the same could be applied to odynophagia scores during the period of all seven postoperative days (p < 0.01) and otalgia scores from the 4th postoperative day (p < 0.05). The sucralfate group patients also had a significantly smaller need for analgesics, better scores of well being in general and early return to regular daily activities with no side effects of the treatment. Topical sucralfate could be recommended for the everyday clinical practice as a safe, adjuvant medicine of treatment during the period of the first post-tonsillectomy week.