Effect of paracetamol/prednisolone versus paracetamol/ibuprofen on post-operative recovery after adult tonsillectomy

Effect of Oral Prednisolone on Pain after Tonsillectomy with Sutures: A Randomized Clinical Trial

Background

Tonsillectomy, one of the most common otolaryngology surgeries, often results in postoperative complications such as pain and bleeding. Currently, there is no consensus on postoperative pain management. This study aimed to determine the efficacy of oral prednisolone on postoperative pain after tonsillectomy with sutures.

Materials and Methods

This pilot, double-blind, randomized clinical trial was conducted at two tertiary care centers affiliated with Isfahan University of Medical Sciences. Patients who underwent tonsillectomy with sutures were included. Participants were randomly divided into experimental and control groups. In the experimental group, patients received oral prednisolone in addition to acetaminophen; in the control group, patients received acetaminophen and a placebo. Post-operative pain was evaluated by a visual analog scale daily for ten days.

Results

Initially, 60 patients were enrolled in the study; however, four were excluded due to non-attendance at follow-up visits. The groups were similar in terms of age and sex (both P values >0.05). In the study, postoperative pain from 1st day to the 10th day was lower in the experimental group than in the control group (P value <0.05).

Conclusion

Numerous studies have been conducted on the effect of intravenous corticosteroids on this pain. However, there is no consensus on the analgesic role of oral corticosteroids for post-tonsillectomy pain. The present study showed that oral prednisolone is effective on post-operative pain compared to a placebo.

Effect of ibuprofen on severity of surgically-managed pediatric post-tonsillectomy hemorrhage

OBJECTIVES

The association between ibuprofen use and severity of post-tonsillectomy hemorrhage (PTH) remains unclear. We aimed to compare PTH severity in patients who did or did not receive ibuprofen.

METHODS

A retrospective cohort study of pediatric patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 was performed. PTH severity was assessed using pre-tonsillectomy and post-hemorrhage hemoglobin and hematocrit values, estimated intraoperative blood loss, estimated hemorrhage flow rate, and need for transfusion. Differences in hemorrhage severity markers between the two cohorts were compared.

RESULTS

A total of 168 consecutive patients were included in this study. The mean age was 8.8 years, and 55.4% of patients were male. Sixty-five patients (38.7%) received ibuprofen postoperatively. There was no statistically significant difference in the mean change in hemoglobin (1.1 vs. 1.1, P = 0.85) or hematocrit (3.1 vs. 3.2, P = 0.97) between patients who received ibuprofen compared to those who did not. Similarly, there were no significant differences in need for transfusion (3.1% vs. 3.9%, P = 1.00) or occurrence of high-flow (arterial) blood loss (33.8% vs. 40.8%, P = 0.42) between the two groups.

CONCLUSION

Postoperative ibuprofen use does not appear to significantly increase PTH severity, as measured by change in hemoglobin and hematocrit values, need for transfusion, or presence of high-flow blood loss. This study introduces previously unexplored markers to assess PTH severity and supports further prospective studies to determine the effect of ibuprofen on PTH severity.

Non-opioid analgesics and post-operative pain following transoral robotic surgery for oropharyngeal cancer

Objective

To investigate associations between multimodal analgesia and post-operative pain among patients undergoing transoral robotic surgery for oropharyngeal squamous cell carcinoma.

Methods

Records of patients who underwent surgery from 5 September 2012 to 30 November 2016 were abstracted. Associations were assessed using multivariable analysis.

Results

A total of 216 patients (mean age of 59.1 years, 89.4 per cent male) underwent transoral robotic surgery (92.6 per cent were human papilloma virus positive, 87.5 per cent had stage T1–T2 tumours, and 82.9 per cent had stage N0–N1 nodes). Gabapentin (n = 86) was not associated with a reduction in severe pain. Ibuprofen (n = 72) was administered less often in patients with severe pain. Gabapentin was not associated with increased post-operative sedation (p = 0.624) and ibuprofen was not associated with increased bleeding (p = 0.221). Post-operative opioid usage was not associated with surgical duration, pharyngotomy, bilateral neck dissections, tumour stage, tumour size, subsite or gabapentin.

Conclusion

Scheduled low-dose gabapentin was not associated with improved pain control or increased respiratory depression. Ibuprofen was not associated with an increased risk of bleeding and may be under-utilised.

Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative

INTRODUCTION

To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP).

MATERIALS AND METHODS

Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider.

RESULTS

Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates.

CONCLUSIONS

The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations

Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.