Posterior pillar mucosal suspension technique for posttonsillectomy pain and wound healing: a prospective, randomized, controlled trial

Can intraoperative suturing reduce the incidence of posttonsillectomy hemorrhage? A systematic review and meta-analysis

Objective

This study was to compare tonsillectomy with intraoperative suturing (TIS) and tonsillectomy without intraoperative suturing (TsIS) in preventing postoperative tonsillectomy hemorrhage (PTH).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was followed. Articles compare TIS and TsIS in preventing PTH were included. The quality of eligible studies was assessed with the Newcastle-Ottawa Scale (NOS) by two independent investigators. Random effect models were used to determine odds ratio (OR) with 95% CIs.

Results

A total of 15 studies were analyzed. The pooled results showed the PTH rate was lower in the TIS group (OR = 0.64; 95% CI, 0.47-0.88). The TIS group had a lower primary and secondary PTH rate than the TsIS group with OR values of 0.44 (95% CI, 0.30-0.64) and 0.70 (95% CI, 0.54-0.90), respectively. However, suturing did not show an advantage in reducing the risk of returning to the operation room for hemostasis (OR = 0.57; 95% CI, 0.13-2.47). Adults might benefit from the intraoperative suturing procedure (OR = 0.31; 95% CI, 0.16-0.60). Patients with more than three stitches on each side had a lower PTH rate (OR: 0.44; 95% CI, 0.32-0.60). Suturing the tonsillar fossa and pillars simultaneously could reduce the PTH rate (OR = 0.47; 95% CI, 0.34-0.64).

Conclusions

Intraoperative suturing is a good strategy for preventing PTH. More multicenter randomized controlled studies should be conducted to demonstrate the efficacy of this procedure.

Level of Evidence

5.

Critical review on the efficacy and safety of levobupivacaine peritonsillar infiltration

Levobupivacaine is a long-acting local anesthetic that is both safe and non-toxic. However, few researchers have examined the efficacy and safety of peritonsillar injections of levobupivacaine for postoperative pain relief. The goal of this study was to assess current randomized controlled trials that employed this strategy. A literature review was conducted using databases such as DELPHIS, PUBMED, COCHRANE, and SCOPUS. A total of fifteen randomized controlled trials were found and thoroughly reviewed. There were no fatalities reported. One study reported a case of nausea and vomiting. In most of the studies, levobupivacaine with magnesium, epinephrine, dexamethasone hydrochloride, tramadol, or levobupivacaine alone were compared to a placebo. Four trials employed different combinations of levobupivacaine and other medicines to recruit adults. Most of the studies had a modest sample size. As a result, larger research with more representative populations should be conducted. Despite certain flaws in the trial design, our findings suggest that levobupivacaine is safe and effective at reducing postoperative pain.

The effect of applying amniotic membrane on post-tonsillectomy pain and bleeding

PURPOSE

Pain and hemorrhage are common morbidities after tonsillectomy. Although many studies have focused on post-tonsillectomy pain, inadequate researches are available on wound healing. Hence, there is a definite need for a novel technique to facilitate the healing process and thereby improving the post-tonsillectomy recovery.

METHODS

This prospective and randomized study was conducted on 60 adult patients who underwent tonsillectomy. They were divided into two groups of control and amniotic membrane (AM). Human amniotic membrane was applied over the tonsillar bed as a biologic dressing. Post-tonsillectomy pain and bleeding were evaluated. Also, the healing rate was assessed on days 5, 10 and 15 post-operatively.

RESULTS

The pain score in the AM group was lower than that in the control group during the first week after surgery (P < 0.0001). Moreover, the AM group returned faster to their normal diet in comparison with the control group (P < 0.0001). With respect to the healing rate, there were no significant differences between the groups on day 5 (P > 0.05), whereas a significant difference was seen on days 10 and 15 post-surgery (P < 0.0001). There was no significant difference between the two groups in terms of post-operative bleeding (P ≅ 1).

CONCLUSION

We observed that the use of AM graft as a biologic dressing might be beneficial in reducing post-operative pain and promoting the wound healing process. The results represent a further step toward developing a new technique for coverage of tonsillar fossa with sheeting or wearing grafts.

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.