Preincisional infiltration with bupivacaine in tonsillectomy

Systematic review and meta-analysis of pain management after tonsillectomy

Tonsillectomy is one of the most common operations. Tonsillectomy is also one of the most painful surgical procedures. However, there is still no satisfactory standard for postoperative pain management. Four databases (Cochrane Library, Ovid Technologies, PubMed, Web of Science) were searched for the period from 1908 to 2019. The systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were pooled using random-effects and fixed-effects models. Randomized controlled trials, reviews and meta-analyses were included. Primary outcomes were quantitative pain intensity in the first 24 h after tonsillectomy and on days 1, 3, and 7 postoperatively. The search yielded 1594 publications, of which 111 publications with 7566 patients, both children and adults, could be included. Intraoperative medication with intravenous dexamethasone significantly reduced pain (mean difference [MD] -0.42; 95% confidence interval [CI]: -0.61- -0.24). Among the local anesthetics, only the preoperative injection of levobupivacaine into the tonsillar compartment was able to provide sufficient pain reduction up to three days after tonsillectomy (MD: -1.92; 95% CI: -2.73 - -1.11). Preoperative or intraoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduced pain (MD: -0.75; 95% CI: -0.87- -0.63). Steroids and NSAIDs are an important part of pain management after tonsillectomy.

Nasal Sprays Containing Mometasone Furoate for Relief of Post-Adenotonsillectomy Pain in Children: A Prospective Controlled Study

Objectives

Adenotonsillectomy is one of most common surgeries performed in childhood. Post-operative pain associated particularly with tonsillectomy is still a problem for many physicians. Despite advances in surgical techniques, analgesics, or anti-inflammatory drugs, no unique strategy for post-tonsillectomy pain management has been suggested. The aim of this study is to investigate the analgesic effect of steroid containing nasal spray applied to tonsillar region after tonsillectomy.

Methods

Eighty-two patients were assigned into two groups as study and control. In study group, nasal spray containing steroid was applied to each tonsillar region after surgery for 5 days. Post-operative pain of all patients was assessed using a visual analog scale and results were compared.

Results

Pain decreased gradually over time in both the study and control groups. Although the pain scores from 4 h post-surgery to post-operative day 5 were not found to significantly decrease in children that used nasal spray containing steroid, these patients developed less pain on post-operative day 5,with statistical significance (p<0.05).

Conclusion

Post-tonsillectomy pain was reported to increase around post-operative day 5, which coincides with the time of intense wound inflammation. Therefore, significant pain reduction on post-operative day 5 observed in children that used nasal spray with steroid may have clinical importance for overcoming this problem.

Efficacy of bupivacaine infiltration for controlling post-tonsillectomy pain, duration of surgery and post-operative morbidities: A systematic review and meta-analysis

The objective of the present review and meta-analysis was to evaluate the efficacy of bupivacaine during tonsillectomy in terms of reducing the mean operative procedure duration, post-operative pain and the onset of post-operative morbidities. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed to perform a systematic literature search using the MEDLINE, Scopus, EMBASE and CENTRAL databases. The present meta-analysis sought to evaluate the efficacy of bupivacaine administered during tonsillectomy as compared to the administration of normal saline. The efficacy of the intervention was evaluated based on pain scores using the visual analogue scale, the duration of the operation and the occurrence of post-operative morbidities. Out of 1,427 records, 15 articles with 729 participants (mean age, 10.2±6.7 years) were included in the study. The present systematic review supported the use of bupivacaine during tonsillectomy at a level of evidence of 1b and confirmed beneficial effects of bupivacaine intervention by demonstrating small to large effect reductions in the visual analog scale score (Hedge's g, -1.48), the mean duration of the operative procedure (Hedge's g, -1.35) and the incidence of post-operative morbidity (Hedge's g, -0.23) in comparison to the placebo groups treated with normal saline. Based on these results, the administration of bupivacaine is recommended during tonsillectomies to reduce the perceived level of pain, the duration of the operation and the post-operative morbidity.

#10-Year Challenge: Local anaesthetic for post-tonsillectomy pain: Update meta-analysis

INTRODUCTION

Adequate management of post-tonsillectomy pain is an important consideration in postoperative management after tonsillectomy. A 2008 meta-analysis showed that the use of local anaesthetic either by infiltration or topical application reduced postoperative pain.

OBJECTIVES

To review the current evidence for the use of local anaesthetic as a means of reducing post-tonsillectomy pain and compare current evidence to the previous meta-analysis 10 years ago.

METHOD

Systematic literature searches of MEDLINE [*"ANESTHETICS, LOCAL"/ AND *TONSILLECTOMY/], EMBASE [*"LOCAL ANESTHETIC AGENT"/ AND *TONSILLECTOMY/] and PubMed [(Tonsillectomy).ti,ab AND (Local Anaesthetic).ti,ab OR (Local Anesthetic).ti,ab]. A meta-analysis of randomised control trials assessing the use of local anaesthetic agents for post-tonsillectomy pain.

RESULTS

Twenty-three studies were included in the meta-analysis. Overall, local anaesthetic, applied topically or infiltrated, significantly reduces pain scores compared with controls at 4-6 hours [-0.65 (95% CI: -0.77; -0.53)]; 24 hours [-0.50 (95% CI: -0.66, -0.35)]; and 5-7 days [-0.78 (95% CI: -0.90, -0.65)] (standardised mean differences).

CONCLUSION

Current studies suggest that use of peri-operative local anaesthetic during tonsillectomy does improve postoperative pain outcomes. The limitations of the analysis are as follows: all studies are small, and a multi-centred larger trial is recommended to guarantee statistical reliability. There was no description of significant adverse side effects from local anaesthetic use.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Introduction  Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective  To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods  In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results  Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo ( p  < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion  We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Does topical use of autologous serum help to reduce post-tonsillectomy morbidity? A prospective, controlled preliminary study

BACKGROUND

To evaluate the effects of autologous serum usage on throat pain, haemorrhage and tonsillar fossa epithelisation in patients after tonsillectomy.

METHODS

Thirty-two patients (aged 4-15 years) were included in the study. Tonsillectomy was performed and autologous serum was administered topically to the right tonsillar fossa during the operation, and at 8 and 24 hours post-operatively. The left side served as the control. A visual analogue scale was used to record the patient's pain every day. Each patient's oropharynx was observed on the 5th and 10th post-operative days to examine bleeding and epithelisation.

RESULTS

The pain scores for the side administered autologous serum were significantly lower than those for the control side, on the night following the operation and on the 1st, 2nd, 5th and 6th post-operative days. Tonsillar fossa epithelisation was significantly accelerated on the study side compared with the control side on the 5th and 10th post-operative days.

CONCLUSION

In tonsillectomy patients, topically administered autologous serum contributed to throat pain relief and tonsillar fossa epithelisation during the post-operative period.

Pre-emptive peritonsillar dexamethasone vs. levobupivacaine infiltration for relief of post-adenotonsillectomy pain in children: a controlled clinical study

OBJECTIVES

To investigate the effects of the pre-emptive local infiltration of dexamethasone vs. levobupivacaine on postoperative pain and morbidity in pediatric adenotonsillectomy patients.

METHODS

A total of 60 patients (32 males and 28 females), aged 3-14 years, were included in this double-blind prospective randomized controlled clinical study from September of 2011 until May of 2012. Patients admitted for adenotonsillectomies after informed consent was obtained from the parents, and randomized into three groups receiving either dexamethasone sodium phosphate (Group 1, mean age 5.9 ± 1.6), levobupivacaine with epinephrine (Group 2, mean age 6.1 ± 2.6), or saline (Group 3, mean age 6.0 ± 3.4). Pain scores at the 1st, 4th, 8th, 12th, 16th, and 20th hours, and first, second, third and seventh days post-operatively were recorded by the parents using McGrath's face scale. The operation type, operation time and anesthesia time, the time of the first request for postoperative analgesia, and the total number of analgesic interventions were recorded.

RESULTS

Pain scores were revealed in this order: Group 1 (steroid) < Group 2 (levobupivacaine) < Group 3 (saline) at all times (p = 0.000). The anesthesia times for Group 1 and Group 2 were different (steroid vs. levobupivacaine), and the time to first analgesic was longer in Groups 1 (steroid) and 2 (levobupivacaine) than in Group 3 (saline) (p < 0.000). The total number of analgesic interventions was lower in Group 1 (steroid) than in Group 2 (levobupivacaine) and Group 3 (saline) (steroid vs. saline, p = 0.000, and steroid vs. levobupivacaine, p < 0.05).

CONCLUSION

Peritonsillar dexamethasone infiltration was more effective than both levobupivacaine and saline in reducing post-tonsillectomy pain. It was proven to be a safe and effective method.

Efficacy of clindamycin in reducing pain following tonsillectomy in adults: a double-blind, randomised trial

OBJECTIVE

Tonsillectomy is a common operation performed in children and young adults. Pain and post-operation haemorrhage are its most common complications. This study was designed to evaluate the efficacy of topical antibiotics in reducing throat pain after tonsillectomy in adult patients.

METHODS

A double-blind, placebo-controlled, randomised clinical trial was conducted, enrolling 30 patients older than 18 years who were scheduled to undergo tonsillectomy. Patients were randomly assigned to receive either clindamycin or normal saline (as placebo). Throat pain severity was evaluated using a visual analogue scale.

RESULTS

All patients in both groups had experienced a reduction in pain by the seventh day after surgery. There was no statistically significant difference in the extent of visual analogue scale pain score reduction, comparing the placebo and clindamycin groups throughout the study course (p = 0.424).

CONCLUSION

Topical clindamycin was not demonstrated to be more effective than normal saline in the reduction of throat pain following tonsillectomy in adults.

The efficiacy of anterior and posterior archs suturation at inferior tonsillar pole for posttonsillectomy pain control

The aim of our study was to investigate the efficiacy of the suturation technique after completing the tonsillectomy procedure for posttonsillectomy pain control in adult patients. August 2010-February 2011, 44 adult patients, ages ranged from 16 to 41 years old who underwent tonsillectomy at Elaziğ Training and Research Hospital Otorhinolaryngology Clinic were included to the study. After tonsillectomy procedure, anterior and posterior tonsillar archs were sutured each other and so, the area of tonsillectomy lodges which covered with mucosa were increased. Twenty two patients who applied posttonsillectomy suturation were used as study group and remnant 22 patients who did not applied posttonsillectomy suturation were used as control group. The visual analogue score (VAS) was used to evaluate the postoperative pain degree (0 no pain, 10 worst pain). ANOVA test (two ways classification with repeated measures) was used for statistical analysis of VAS values. P < 0.05 was accepted as statistically significant. The effect of time (each post-operative day) on VAS values was significant. The mean VAS values between study and control group on post-operative day 1st, 3rd, 7th, and 10th were statistically significant (P < 0.05). The severity of posttonsillectomy pain was less in study group patients than control group patients. The suturation of anterior and posterior tonsillar archs after tonsillectomy procedure was found effective to alleviate the posttonsillectomy pain in adult patients.

Comparison of two different local anaesthetic infiltrations for postoperative pain relief in tonsillectomy: a prospective, randomised, double blind, clinical trial

In previous studies, it was shown that the post-tonsillectomy wound infiltration of bupivacaine can reduce postoperative pain. The objective of this study is to determine whether the postoperative wound infiltration with a mixture of bupivacaine, mepivacaine and adrenaline is more effective than the sole application of bupivacaine. A prospective, double-blind, randomized, control study included 30 patients scheduled for "cold steel" tonsillectomy. All patients obtained post-tonsillectomy infiltration of 6.25 mg bupivacaine alone on one side and 3.75 mg bupivacaine, 25 mg mepivacaine and 0.0125 mg epinephrine on the other side (intra-individual study design). Intake of analgesics and postoperative pain was assessed 0-6 days after surgery by visual analogue scale in inactivity and during swallowing by the nurse staff. Bleeding, dysphagia, pain, aspiration or extraordinary pain sensation were registered by the patient. The pain scores did not differ between the groups. All patients received systemic painkillers; 6 (20%) patients needed intravenous analgesics. Postoperative haemorrhage occurred in two patients without correlation to a certain local anaesthetic. Two patients developed sinus tachycardia for 2.5 min after epinephrine infiltration. Because of cost-effectiveness and complication rates, we recommend only post-tonsillectomy wound infiltration of bupivacaine. The injection should be placed in superficial muscle and connective tissue. A stringent systemic analgesia regime is indispensable for pain relief after tonsillectomy.

The effects of topical levobupivacaine on morbidity in pediatric tonsillectomy patients

OBJECTIVE

To reduce the post-tonsillectomy morbidity by swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml).

STUDY DESIGN

A double-blind prospective randomized controlled clinical study.

METHODS

In this randomized double-blind study in group I (30 children, mean age 7.5+/-2.6) we tightly packed swab soaked with 5 ml levobupivacaine hydroclorur (25mg/10 ml) and in group II (21 children, mean age 7.9+/-3.7) we used 5 ml saline swabs into each of the two tonsillar fossae after tonsillectomy for 5 min. We used McGrath's face scale to compare the two groups in respect of pain control.

RESULTS

There was statistically significant pain relieving effect in the levobupivacaine group in the first 24h (p<0.05). But after 24h pain relieving effect of levobupivacaine was not significant (p>0.05). We did not see any serious complications for both groups. Postoperative morbidity mean results (nausea, vomiting, fever, bleeding, halitosis and ear pain) were not statistically different between the two groups (p>0.05).

CONCLUSION

Topical levobupivacaine seems to be a safe and easy medication for postoperative pain control in pediatric tonsillectomy patients.

Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study

OBJECTIVE

To evaluate three current tonsillectomy techniques--intracapsular microdebridement, intracapsular coblation, and traditional extracapsular electrocautery dissection--comparing surgical parameters, efficacy, and morbidity in the treatment for obstructive sleep disordered breathing in children.

STUDY DESIGN

Prospective, double-blinded study with follow-up by telephone interview.

METHOD

From February 2004 to July 2006, a total of 156 patients between the ages of 6 months and 22 years scheduled for adenotonsillectomy were randomly assigned to electrocautery, coblator, and microdebrider groups.

OUTCOME MEASURES

1) Patient demographics; 2) Intraoperative time; 3) Surgeon's perception of difficulty; 4) Indicators of postoperative morbidity: pain, use of pain medication, return to diet, and activity level; 5) Complications; 6) Cost.

RESULTS

Microdebrider technique produced the shortest total surgical time, averaging 16 minutes. Use of coblation resulted in 2 less days of pain medication compared to electrocautery. Patients in the coblator and microdebrider groups returned to a normal diet 1.51 days and 1.77 days earlier, respectively, than in the electrocautery group. They also returned to preoperative activity levels 1.85 days and 2.06 days earlier than in the electrocautery group. Of all three methods, the microdebrider was the most cost effective. The coblator and microdebrider did not differ significantly from each other in all other parameters. The three techniques showed no statistically significant difference in assessment of difficulty, average pain scores, or postoperative complications.

CONCLUSIONS

Postoperative recovery following intracapsular adenotonsillectomy in children with obstructive sleep apnea is significantly earlier with use of either the coblator or microdebrider versus traditional extracapsular tonsillectomy with electrocautery. Microdebrider and coblator were comparable in all other areas except for shorter operative time and less cost for the microdebrider.

Ropivacaine Peritonsillar Infiltration for Analgesia after Adenotonsillectomy in Children: A Randomized, Double-Blind, Placebo-Controlled Study

Objectives:

Our randomized, double-blind, placebo-controlled study evaluates the possible benefit of peritonsillar infiltration with 0.75% ropivacaine hydrochloride on the pain level after adenotonsillectomy in 3- to 7-year-old children.

Methods:

We randomly administered intraoperative peritonsillar infiltration with 0.2 mL/kg ropivacaine 0.75% (group R) or 0.2 mL/kg saline 0.9% (group F) to sixty 3- to 7-year-old children (ASA 1 or 2) who were undergoing adenotonsillectomy. Postoperative pain was assessed 6 and 24 hours after surgery by a 6-face Faces Pain Scale that allowed quantification of pain on a 100-mm horizontal line (0 = no pain). The number of rectal doses of acetaminophen-codeine required during the first postoperative day was recorded.

Results:

The pain scores did not differ between the groups, either 6 or 24 hours after surgery (group F, 43 ± 26, versus group R, 29 ± 23, and group F, 24 ± 23, versus group R, 30 ± 28, respectively). Acetaminophen-codeine doses were similarly required in the two groups.

Conclusions:

Peritonsillar infiltration with 0.75% ropivacaine does not provide any major postoperative analgesic effect in 3- to 7-year-old children after adenotonsillectomy. A possible clinically minor analgesia 6 hours after surgery is suggested.

Effects of intramuscular and peritonsillar injection of tramadol before tonsillectomy: a double blind, randomized, placebo-controlled clinical trial

BACKGROUND/AIMS

Our objective was to investigate the efficacy of intramuscular injection and peritonsillar infiltration of tramadol to prevent pain in children undergoing tonsillectomy.

METHODS

In a double-blinded trial, 45 children were randomized into three groups: infiltration anesthesia with tramadol (2 mgkg(-1)) to the peritonsillar area (INF group, n=15), intramuscular analgesia with tramadol (2 mgkg(-1)) (IM group, n=15), and the placebo controls (PL group, n=15). Visual analog scale (VAS) scores for pain assessment, heart rate (HR) and mean arterial pressure (MAP) during and after anesthesia were recorded.

RESULTS

Mean HR values were higher in INF than PL group at 10th, 20th, and 30th minutes of operation (P<0.05). Nine children required analgesics within the first hour after surgery in PL compared to 1 child in INF group (P=0.036). VAS scores on awakening were significantly better in INF than PL group (P=0.015). The difference between IM and PL groups was not significant for any of the parameters.

CONCLUSION

Peritonsillar infiltration with tramadol provided good intraoperative analgesia, less postoperative pain on awakening and lower analgesic requirement within the first hour after surgery.

Prospective, Double-Blinded, Randomized, Placebo-Controlled Comparison of Local Anesthetic and Nonsteroidal Anti-Inflammatory Drugs for Postoperative Pain Management after Laparoscopic Surgery

Compared with the open approach, laparoscopy has been shown to significantly reduce postoperative pain. Improving postoperative analgesia in laparoscopic surgery is an area of continued interest. The goal of this study was to compare the efficacy of local anesthetic infiltration with or without preoperative nonsteroidal anti-inflammatory drugs. Patients undergoing elective laparoscopic cholecystectomy were enrolled in an Institutional Review Board-approved, prospective, double-blinded, randomized, placebo-controlled comparison study. Patients were randomized into four groups: Group I, preoperative oral administration of a placebo medication and prein cision local infiltration of 40 mL of 0.5 per cent bupivicaine at trocar sites; Group II, preoperative oral administration of 50 mg of rofecoxib; Group III, preoperative oral administration of 50 mg of rofecoxib and preincision local infiltration of 40 mL of 0.5 per cent bupivicaine into skin, muscle, and peritoneum; and Group IV, preoperative oral administration of a placebo medication. Postoperative pain scores were assessed at 4 hours, 8 hours, 12 hours, and 24 hours using a visual analog scale. Postoperative analgesic use, complications, and length of stay were recorded. Statistical significance was defined as P < 0.05. Fifty-five patients (46 women and 9 men) were enrolled in this study and underwent a standardized, elective, laparoscopic cholecystectomy for mild, symptomatic cholelithiasis (96.4%) and gallbladder polyps (3.6%). No patient had pain immediately before surgery. Postoperative analgesic requests, visual analog scale results, incidence of postoperative vomiting at 4 hours, 8 hours, 12 hours, and 24 hours, in addition to length of stay, were not statistically different between the four groups. No complications occurred. The use of preoperative rofecoxib, 0.5 per cent bupivicaine infiltration, or both for postoperative analgesia did not decrease postoperative pain or decrease length of stay after laparoscopic cholecystectomy compared with placebo. Preoperative administration of an oral anti-inflammatory pain medication, infiltration of a local anesthetic, or both had no greater effect than placebo in controlling discomfort after a laparoscopic cholecystectomy. The challenge of preempting postoperative pain continues and will require further investigation.

Comparison of bupivacaine and ropivacaine on postoperative pain after tonsillectomy in paediatric patients

BACKGROUND

We aimed to compare the effects of peritonsillar bupivacaine and ropivacaine infiltration on pain after tonsillectomy in children.

METHOD

Sixty patients were randomly allocated to three groups: pertonsillar infiltration with bupivacaine (group B), ropivacaine (group R) and normal saline (group S). Pain scores with visual analogue scale (VAS) and sedation scores were assessed during postoperative 24h. Choice of additional analgesic was acetaminophen for all patients.

RESULTS

VAS was significantly lower in groups B and R, during the first half hour, while it was lower in group B than those in groups R and S at postoperative second and sixth hours. Time to first analgesic treatment was significantly longer in groups B and R. Total acetaminophen consumption was lower in group B than those in group S. Sedation scores were higher in group B than in groups R and S until postoperative second hour but there were significant difference only at postoperative fifth minutes.

CONCLUSION

Peritonsillar bupivacaine infiltration is, however, insufficient to control postoperative pain, it is more effective than ropivacaine for reducing postoperative analgesic requirement.

Adjuvant local anaesthetics in the epipharyngeal space in day-case adenoidectomy: a prospective, randomized, double-blind, placebo-controlled trial

CONCLUSION

Mepivacaine applied in the epipharyngeal space as an adjuvant local anaesthetic does not reduce postoperative pain after adenoidectomy in children given high-dose paracetamol preoperatively.

OBJECTIVE

To evaluate the pain-reducing effect of an adjuvant local anaesthetic (mepivacaine) applied in the epipharyngeal space after outpatient adenoidectomy.

MATERIAL AND METHODS

This was a prospective, randomized, double-blind, placebo-controlled trial. Postoperative pain was assessed in 98 children aged 3-10 years using a visual analogue scale (VAS) and the Wong-Baker FACES pain rating scale. The time between the end of surgery and discharge from hospital was recorded, as well as the need for extra pain medication in addition to the high-dose paracetamol (acetaminophen) that had been given preoperatively. Serum levels of mepivacaine were analysed in 10 consecutive patients.

RESULTS

No difference was seen between the mepivacaine and control groups regarding postoperative pain as estimated using either the VAS or the Wong-Baker FACES pain rating scale. There were also no differences between the groups concerning the time to discharge from hospital and the need for extra pain medication before discharge. No mepivacaine could be detected in the patients' sera.

Pre-incisional infiltration for pediatric tonsillectomy: a randomized double-blind clinical trial

OBJECTIVE

Tonsillectomy is frequently associated with post-operative pain of considerable duration. The aim of the current study is to corroborate our previous observational data by conducting a prospective double-blind placebo-controlled randomized clinical trial to determine the potential effect of pre-incision infiltration of local anesthesia on post-operative pain after tonsillectomy.

DESIGN

Randomized double-blind controlled clinical trial.

SETTING

Tertiary care facility in Beirut, Lebanon.

PATIENTS

Ninety patients who underwent tonsillectomy allocated evenly in three groups.

INTERVENTIONS

Pre-incision infiltration of 1.5 local anesthetic mixture in each tonsil was performed in conjunction with general anesthesia (infiltration, n=30). Pre-incision infiltration of 1.5 ml of 0.9% of normal saline was applied with general anesthesia (placebo, n=30). GA received only general anesthesia.

OUTCOME MEASURES

Post-operative pain at rest, eating soft diet, jaw opening at 0, 6, 12, and once daily for the 10-day follow-up period, hemodynamic stability, hospital stay, parent and surgeon satisfaction, ear pain and analgesics consumption were assessed.

RESULTS

Hemodynamic stability was maintained during pre, per and post-operation. 93.1% of infiltration group left the hospital the same day compared to 60% in placebo groups and 41.4% in general anesthesia group (p=0.001). Surgeon's satisfaction was significantly higher in infiltration group compared to placebo and general anesthesia groups (p=0.001). Parent's satisfaction was significantly higher in infiltration group (89.65%) compared to general anesthesia group (13.8%) and placebo group (36.7%) (p=0.001). The average pain scores at rest, on jaw opening and when eating soft diet were significantly lower in infiltration group compared to placebo group and general anesthesia group (p<0.05). Analgesic consumption in placebo and general anesthesia groups were significantly higher compared to infiltration group (p<0.05).

CONCLUSION

This modified pre-incision infiltration of anesthetic mixture combined with general anesthesia reduces significantly post-tonsillectomy pain in children and provides a more rapid return to normal activity compared to general anesthesia alone or in combination with a placebo infiltration.

Does topical lidocaine with adrenaline have an effect on morbidity in pediatric tonsillectomy?

OBJECTIVE

To evaluate the efficacy of lidocaine with adrenaline on post-operative morbidity in pediatric patients after tonsillectomy.

STUDY DESIGN

A double blind prospective randomized controlled clinical study.

METHODS

The study is consisting of two groups of pediatric patients following tonsillectomy performed in a university hospital. One group received lidocaine with adrenaline soaked swabs packed in their tonsillar fossae while the control group received saline-soaked swabs. Chi-square and two-tailed unpaired Student's t-tests were used to compare the two independent groups. p<0.05 was accepted as statistically significant.

RESULTS

No significant pain-relieving effect was seen in the lidocaine with adrenaline group (p>0.05) and also the other post-operative parameters such as nausea, fever, vomiting, odor, bleeding, otalgia and trismus were not statistically different between the two groups based on chi-square analysis (p>0.05). There were no complications associated with lidocaine and adrenaline.

CONCLUSION

We suggest that application of topical lidocaine with adrenaline seems to be a safe and easy medication for local anesthetic use. However, in our study, lidocaine with adrenaline offered no advantage over placebo in the control of post-operative pain and other morbidity related factors following pediatric tonsillectomy. We therefore do not recommend topical application of lidocaine with adrenaline for reducing morbidity in pediatric tonsil surgery.

Current practice patterns in tonsillectomy and perioperative care

OBJECTIVES

Tonsillectomy is one of the most commonly performed otolaryngologic procedures in the United States. Many options and controversies exist regarding techniques and peri-operative management. The purpose of the study was to examine current practice patterns among otolaryngologists regarding tonsillectomy.

METHODS

A 13 question survey regarding tonsillectomy techniques and peri-operative management was mailed to 10% of randomly selected board certified otolaryngologists of the AAO-HNS in the spring of 2002. Four hundred and eighteen anonymously completed questionnaires were returned, for a response rate of 58.5%. Statistical analysis of survey data was performed by means of cross tabulation and Pearson Chi-Square Calculation.

RESULTS

Monopolar electrocautery was the most common technique used among those surveyed (53.5%). There was a significant correlation between choice of monopolar electrocautery and the cited reason for choice of technique being decreased blood loss (P < 0.001). There was no relationship between pediatric fellowship training and choice of technique. 97.7% routinely admitted sleep apnea patients for post-operative observation. There was no significant correlation between practice setting (tertiary versus community) and type of post-operative monitoring for sleep apnea patients, with patients most commonly admitted to an intermediate care setting.

CONCLUSION

In our survey, the most common surgical technique for tonsillectomy was monopolar electrocautery, chosen for the reason of decreased blood loss.

The effects of dexamethasone, bupivacaine and topical lidocaine spray on pain after tonsillectomy

OBJECTIVE

To compare the administration of bupivacaine hydrochloride, dexamethasone and lidocaine hydrochloride in decreasing post-tonsillectomy pain.

METHODS

Eighty patients were enrolled in the study in ENT Clinic, Firat University, and in ENT Clinic Elaziğ SSK Hospital, Elaziğ (Turkey). Children between 6 and 14 years of age referred to our department for bilateral tonsillectomy for either recurrent tonsillitis or tonsillar hypertrophy. Data from 80 patients were analyzed. The first group had bupivacaine hydrochloride. The second group had dexamethasone infiltrated around each tonsil. The third group was given equal doses of 10% lidocain hydrochloride sprayed on the tonsillectomy fossa four times a day, and a placebo group received 9% NaCl applied to the tonsillar fossa four times a day. Pain scores, determined by visual analog scale, were obtained in the first, third and seventh postoperative days.

RESULTS

Pain scores in the postoperative period were identical in the first, third and seventh postoperative days. According to VAS results the groups were compared on the basis of postoperative pain. In the first postoperative day, the difference between bupivacaine-placebo, dexamethasone-placebo and lidocaine-placebo groups was found to be statistically significant (P<0.05). Nevertheless the difference between bupivacaine-dexamethasone, bupivacaine-lidocaine and dexamethasone-lidocaine were not significant (P>0.05). In the third postoperative day, the difference between bupivacaine and lidocaine group found to be statistically significant (P<0.05). In the seventh post-operative day the results of bupivacaine, dexamethasone, lidocaine and placebo groups were similar (P>0.05).

CONCLUSION

Bupivacaine, Dexamethasone and Lidocaine nasal aerosol decreased the pain significantly in the first postoperative day when it was compared with the placebo group. These three medicines can be used to reduce pain for children during the postoperative period applied tonsillectomy during the post-operative period. But lidocaine was more preferable, reducing pain in the third postop day better than bupivacaine.

Beneficial effect of low-dose peritonsillar injection of lidocaine-adrenaline before tonsillectomy. A placebo-controlled clinical trial

OBJECTIVE

Most studies investigating the effect of preincisional injection of local anaesthetic with adrenaline in tonsillectomy have used rather large doses and an inter-individual study design. They are inconclusive regarding the effect on post-tonsillectomy pain but have shown that the peroperative blood loss is reduced. However, side effects to high adrenaline doses are common. In the present study, the effect of injecting a small dose of lidocaine-adrenaline was investigated by using an intra-individual study design.

METHODS

In this randomised double-blind study 52 patients (33 women and 19 men) received unilateral preincisional injection of 3-ml lidocaine-adrenaline before tonsillectomy.

RESULTS

the difference in blood loss was highly significant with a more than 50% reduction in peroperative blood loss in the infiltrated side. Time to achieve haemostasis for one tonsil side was reduced from 6.0 to 4.0 min. No side effects were observed. At the operation day (mean 4.9 h after operation), the visual analogue scale for pain at the side infiltrated with local anaesthetics was 2.78 compared to 4.00 in the control side (P=0.05).

CONCLUSION

Low-dose injection of lidocaine-adrenaline before tonsillectomy reduces blood loss and has a small but significant beneficial effect on early postoperative pain. Furthermore our results indicate that operation time is reduced. We therefore recommend subcapsular injection of 3 ml of 1% lidocaine with 1/200.000 adrenaline under each tonsil before tonsillectomy.

Adjuvant therapies in children undergoing adenotonsillectomy

OBJECTIVE

To review adjuvant therapies used in children undergoing adenotonsillectomy, addressing several areas of controversy.

STUDY DESIGN

Review.

METHODS

Studies of perioperative injection of local anesthetic agents, postoperative use of antibiotics, perioperative use of intravenously administered steroids, and pain management in adenotonsillectomy were reviewed.

RESULTS

Controversy exists about all adjuvant therapies discussed. Injection of local anesthetics may reduce pain and bleeding but has been associated with several serious side effects. Most patients receive antibiotics postoperatively, but no consensus exists about the agent of choice or duration of its use and there is concern about development of bacterial resistance. A meta-analysis found that children given steroids perioperatively were less likely to have an episode of emesis, but the analysis could not assess the role of steroids in pain control because of a lack of data. The effectiveness of acetaminophen alone compared with acetaminophen plus a narcotic for analgesia after adenotonsillectomy is controversial.

CONCLUSION

Adjuvant therapies have many possible benefits for children undergoing adenotonsillectomy, but otolaryngologists must make careful choices about these treatments.

Grafting of the peritonsillar fossa with an acellular dermal graft to reduce posttonsillectomy pain

PURPOSE

Adult tonsillectomy is a common surgical procedure that is accompanied by masked postoperative pain. Analgesics are usually only partially effective, and the use of narcotics such as codeine is often poorly tolerated because of associated nausea. Because the pain associated with tonsillectomy is believed to arise from the large areas of exposed parapharyngeal muscle, we hypothesized that acellular dermal grafting of the peritonsillar fossa, providing biologic coverage to these areas, would result in a notable reduction of postoperative pain.

MATERIALS AND METHODS

We did a double-blind, prospective study, with 10 adult patients undergoing electrodissection tonsillectomy concurrently with grafting of 1 peritonsillar fossa with an acellular dermal graft (ADG) (AlloDerm, LifeCell Corp, The Woodlands, TX), whereas the other side of the throat received no treatment and was designated as the control side. Patients were examined on postoperative days 1, 7, and 14, and completed pain questionnaires on postoperative days 1, 3, 5, 7, and 14.

RESULTS

ADG grafting of the peritonsillar fossa resulted in a statistically significant reduction in pain (by approximately 50%) on postoperative days 1, 3, 5, and 7, compared with the control side. Two patients experienced partial graft sloughing within the first 10 postoperative days, but no other untoward effects such as bleeding, graft aspiration, or infection, were associated with ADG of the peritonsillar fossa.

CONCLUSIONS

This study suggests that AlloDerm grafting of the peritonsillar fossa is a potentially useful, alternative means of reducing pain in the adult tonsillectomy patient and has potential use in reconstruction of oropharyngeal defects. Because of the cost of the graft, we suggest its use in selected difficult adult cases, but not as part of routine adult tonsillectomy.

Improved postoperative pain control in pediatric adenotonsillectomy with dextromethorphan

DESIGN

A prospective, randomized, double-blinded, placebo-controlled protocol.

SETTING

An academic, tertiary care referral center.

PATIENTS

Forty randomly selected children, ages 3 to 13 years, scheduled for adenotonsillectomy without other simultaneous procedures.

INTERVENTION

A single, oral dose of dextromethorphan pediatric cough syrup (1 mg/kg) or placebo given 30 minutes before surgery.

MAIN OUTCOME MEASURE

Total dose requirement of intravenous morphine within a 6-hour postoperative observation period.

RESULTS

During routine postoperative observation, significantly fewer patients in the dextromethorphan group required no intravenous morphine compared with the placebo group (P =.03). Of those children requiring morphine, the mean dose requirement was significantly lower in the dextromethorphan group (P =.02). There was no known drug-related morbidity.

CONCLUSION

Dextromethorphan syrup is a safe, non-narcotic medication that significantly reduced the requirement of intravenous morphine after pediatric adenotonsillectomy. Its routine use in this manner is recommended.

I.v. ketoprofen for analgesia after tonsillectomy: comparison of pre- and post-operative administration

We have evaluated the safety and efficacy of ketoprofen during tonsillectomy in 106 adults receiving standardized anaesthesia. Forty-one patients received ketoprofen 0.5 mg kg(-1) at induction ('pre' ketoprofen group) and 40 patients after surgery ('post' ketoprofen group), in both cases followed by a continuous ketoprofen infusion of 3 mg kg(-1) over 24 h; 25 patients received normal saline (placebo group). Oxycodone was used for rescue analgesia. Patients in the ketoprofen groups experienced less pain than those in the placebo group. There was no difference between the study groups in the proportion of patients who were given oxycodone during the first 4 h after surgery. However, during the next 20 h, significantly more patients in the placebo group (96%) received oxycodone compared with patients in the 'pre' ketoprofen group (66%) and the 'post' ketoprofen group (55%) (P=0.002). Patients in the placebo group received significantly more oxycodone doses than patients in the two ketoprofen groups (P=0.001). Two patients (5%) in the 'pre' ketoprofen group and one (3%) in the 'post' ketoprofen group had post-operative bleeding between 4 and 14 h. All three patients required electrocautery.

A randomised controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients

Post-operative pain is the main cause of morbidity following tonsillectomy. The efficacy of glossopharyngeal and lesser palatine nerve blocks in controlling postoperative pain in adult patients was investigated prospectively. Patients 16 years and older admitted for elective tonsillectomy were randomised to one of three groups to receive a pre-incisional oropharyngeal injection of 0.5% bupivicaine, a 'dummy' injection of saline or no injection. Dissection tonsillectomy and general anaesthetic techniques were standardized. Postoperative pain was monitored for 24 h. ANOVA, chi2 and Fisher's exact test were used for intergroup comparisons. Ninety-two patients (72 women and 20 men), mean age 22 years were studied. Twenty-nine patients received 0.5% bupivicaine, 30 saline and 33 no pre-incisional injection. The overall mean pain scores of 2.1, 1.9 and 1.9 in the bupivicaine, saline and no injection groups were similar. Glossopharyngeal and lesser palatine 0.5% bupivicaine nerve blocks are not effective in reducing early post-tonsillectomy pain.

Reducing post-tonsillectomy pain with cryoanalgesia: a randomized controlled trial

OBJECTIVE/HYPOTHESIS

To evaluate the use of cryoanalgesia in reducing post-tonsillectomy pain.

STUDY DESIGN

A prospective, randomized double-blind study of 59 consecutive patients (age range, 8-40 y) undergoing tonsillectomy for recurrent tonsillitis.

METHODS

All patients underwent bipolar tonsillectomy. At the completion of the tonsillectomy patients were randomly assigned to a control or a cryotherapy group. The cryotherapy patients had both their tonsillar fossa "supercooled" to between -20 degrees C and -32 degrees C for 1 minute. Patients recorded their pain using a visual analogue scale over the next 10 days. Patients were also monitored for postoperative complications, time until resumption of a normal diet, time back to work or school, and analgesic consumption.

RESULTS

The two groups were similar for age and sex. There was a 28.3% reduction in mean pain scores over the 10 days in the cryotherapy compared to the control group. This difference did not significantly depend on the day after operation or time of the day. Cryotherapy patients also returned to work or school, on average, 4 days earlier than controls. There was no significant difference in postoperative complications between the two groups.

CONCLUSION

Cryotherapy is a new technique that significantly reduces post-tonsillectomy pain without evidence of causing additional complications.

Perioperative local anaesthesia for reducing pain following tonsillectomy

BACKGROUND

Pain relief after tonsillectomy is an important part of post-operative management. Sometimes local anaesthetics are administed to the tonsillar region, but their effectiveness in relieving pain has not been formally assessed.

OBJECTIVES

To assess the effects of pre- and post-operative local anaesthesia for pain reduction following tonsillectomy.

SEARCH STRATEGY

Cochrane Controlled Trials Register, Medline, Embase and the Oxford Pain Database. Reference lists from identified publications, including those in non-English language publications, were scanned. Date of the most recent search was September 1998.

SELECTION CRITERIA

Randomised controlled trials of adults and/or children undergoing tonsillectomy alone with local anaesthetic (a) injected into the tonsillar region immediately prior to removal of the tonsils (b) injected into the tonsillar region after removal of the tonsils (c) sprayed or otherwise applied to the tonsillar region after removal of the tonsils Outcome measures included the reduction in demand for post-operative analgesia, both in terms of time elapsed to request for first analgesia and of the total amount of analgesia used.

DATA COLLECTION AND ANALYSIS

All three reviewers extracted data independently and assessed trials for quality. Four authors were contacted to obtain information on either the method of randomisation or the type of intervention used.

MAIN RESULTS

Thirty trials were initially identified but only six trials met the inclusion criteria. These were all published in the English language literature between 1989 and 1997. Trials were excluded because procedures in addition to tonsillectomy were undertaken, inadequate randomisation techniques were used or because group sizes were inadequate. Of the six included studies, five involved local anaesthetic injection and one application of local anaesthetic spray. These studies used validated pain scores and measurement of supplemental analgesic intake for assessment of pain. However, some studies also included inappropriate, possibly post-hoc, outcome measures such as 'global pain scores' which may have resulted in bias. No included study showed a significant difference between intervention and control, other than for outcome measures which were felt to be inappropriate, such as the one mentioned above.

REVIEWER'S CONCLUSIONS

There is no evidence that the use of perioperative local anaesthetic in patients undergoing tonsillectomy improves post-operative pain control. The trials identified were of small size and several involved the perioperative co-administration of intravenous opiates which may have masked any beneficial effect of the local anaesthetic. Further randomised controlled trials are necessary.

Effect of bupivacaine on pain after tonsillectomy: a randomized clinical trial

Several authors have found that pre-incisional injection of local anaesthetics reduces postoperative pain. In the present double-blind study, comprising 126 inpatients aged 6-42 (mean 19) years, we investigated whether pre-incisional injection of bupivacaine during general anaesthesia reduces the pain experienced after tonsillectomy. The patients were randomized into three treatment groups: 43 patients were injected with 5 ml of bupivacaine (2.5 mg/ml)+ epinephrine (5 microg/ml) solution in both tonsillar fossa, 41 had epinephrine (5 microg/ml) + saline (9 mg/ml) and 42 patients received saline (9 mg/ml) only. Self-assessment of pain during the first postoperative week (repeated measures) was recorded. Use of analgetics, experience of the surgeons, peroperative bleeding and several other clinical parameters were assessed. Analyses of covariance with repeated measures was carried out for each pain score. In general there was no statistical significant difference in pain scores, represented by a visual analogue scale (VAS) between the three treatment groups. However, injection of bupivacaine into the tonsillar fossa seemed to reduce pain shortly after the operation in the age group 19-24 years. Further, females and older patients reported more pain and used more analgetics than males and younger patients. Increasing experience of the surgeon was related to a lower score for baseline pain shortly after the operation. Epinephrine in bupivacaine or saline reduced peroperative bleeding. We conclude that bupivacaine does not provide significant postoperative analgesia after tonsillectomy in an unselected group of patients.

A prospective randomized double-blind trial of fibrin glue for pain and bleeding after tonsillectomy

OBJECTIVES

The notable morbidity of tonsillectomy includes considerable postoperative pain and a rate of postoperative bleeding that have remained largely uninfluenced by modern surgical techniques or medication. Fibrin glue is known to have a hemostatic effect in some settings, and there is research suggesting it may also reduce postoperative pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy.

STUDY DESIGN

A prospective randomized double-blind study was performed on 50 consecutive adult patients undergoing tonsillectomy for chronic tonsillitis.

METHODS

After removal of both tonsils the tonsillar fossa randomly assigned to the treatment protocol was coated with fibrin glue. The other side was left unaltered. The patient was then monitored for postoperative bleeding and wound healing, and a patient-based pain assessment instrument was used to evaluate symptoms every 8 hours for 10 days after surgery.

RESULTS

Detailed evaluation of the pain scores allowed the authors to create a pain profile for what the typical patient experiences over the first 10 postoperative days, as well as during the course of a single day. The pain remains relatively constant for the first 7 days and begins to decrease only on the eighth postoperative day. During a single day there is increased pain in the morning compared with noon and evening. However, no statistically significant difference was detected in postoperative pain, bleeding, or healing between the wounds treated with fibrin glue and controls.

CONCLUSIONS

The patient-based pain evaluation data should aid the physician in preoperative outcome counselling and targeted prescription of pain medication. However, contrary to previous indications, the authors cannot substantiate a significant beneficial effect of fibrin glue in postoperative pain control. Furthermore, we did not find its action as a hemostatic agent clinically applicable in this setting, and thus find no indication for the routine use of fibrin glue in tonsillectomy.