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

Comparative Effectiveness of Analgesia for Early Pain Management After Pediatric Tonsillectomy: A Systematic Review and Network Meta-Analysis

BACKGROUND

Timely and effective analgesia after tonsillectomy in children is crucial, but there is currently no consensus on the optimal analgesics. This analysis aimed to identify the most effective for this surgery.

METHODS

We conducted a systematic review and network meta-analysis (random-effects model) of randomized controlled trials comparing analgesics for pediatric tonsillectomy. We searched relevant studies in PubMed, Embase, Cochrane Library, and Web of Science databases from database inception until June 30, 2023. Children (≤18 years old) who underwent tonsillectomy with or without adenoidectomy were eligible for inclusion. Primary outcomes encompassed pain score and postoperative complications; secondary outcomes included postoperative supplementary analgesia, functional evaluation, and sedation score.

RESULTS

In total 82 randomized controlled trials involving 6110 patients were included, forming the primary network that comprised comparative data for 16 different interventions (including placebo) across 6 types of analgesics. The integrated analysis revealed that nonsteroidal anti-inflammatory drugs except ketoprofen had no significant effects in relieving postoperative pain (mean difference [MD], -2.96; 95% confidence interval [CI], -5.59 to -0.32; P = .10). Local anesthetic infiltration (bupivacaine: MD, -2.76; 95% CI, -3.88 to -1.64, P = .01; ropivacaine: MD, -2.49; 95% CI, -4.25 to -0.73, P = .02; lidocaine: MD, -1.86; 95% CI,-3.52 to -0.2, P = .02; levobupivacaine: MD, -1.06; 95% CI, -2.00 to -0.12, P = .01), analgesics (morphine: MD, -2.07; 95% CI, -3.14 to -1.00; P = .02), and glucocorticoids (dexamethasone: MD, -0.45; 95% CI, -0.73 to -0.16; P = .01) were effective in relieving pain after pediatric tonsillectomy. In reducing incidence of postoperative complications, dexamethasone was superior to bupivacaine (relative risk [RR], 0.60; 95% CI, 0.43-0.83; P = .02). Regarding the number of patients needing rescue analgesic, levobupivacaine was superior to lidocaine (RR, 0.51; 95% CI, 0.32-0.81; P = .01). In rescue analgesia requirement, morphine outperformed lidocaine (RR, 0.44; 95% CI, 0.25-0.75; P = .01) and ropivacaine (RR, 0.54; 95% CI, 0.32-0.91; P = .01) in efficacy but not different from bupivacaine (P = .10) and levobupivacaine (P = .12).

CONCLUSIONS

Based on these results, we would recommend local bupivacaine infiltration or local levobupivacaine infiltration for older children and dexamethasone injection for younger children for early analgesia after tonsillectomy. However, clinicians should choose the optimal analgesic based on the individual child's condition and clinical situation.

Glossopharyngeal Nerve Block for the Management of Post-Tonsillectomy Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To assess the effectiveness of glossopharyngeal nerve block (GNB) in the treatment of postoperative pain among patients undergoing tonsillectomy, a systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. Various databases, including PubMed, Cochrane, Scopus, Web of Science, and Google Scholar, were systematically screened from inception until March 2023. The included studies were assessed using the RoB-2 tool. The outcomes of interest included reporting on at least one of the predetermined efficacy and safety endpoints, such as postoperative pain, the severity of swallowing, and the incidence of postoperative complications such as bleeding, nausea and vomiting, hoarseness, nasal obstruction, dyspnea, foreign body sensation, and dry mouth. Dichotomous data were collected as risk ratios (RR), and continuous data were collected as standardized mean differences (SMD). The overall analyses were conducted using a random-effects model. In total, 492 participants were enrolled in our investigation, with 245 and 247 participants allocated to the GNB and control arms, respectively. When comparing postoperative pain levels during rest and swallowing, the GNB arm showed a significantly reduced effect size compared to the control arm (n = 5 RCTs, SMD= -1.38, 95% CI [-1.82, -0.94], p < 0.001; n = 4 RCTs, SMD= -1.43, 95% CI [-2.15, -0.72], p < 0.001), respectively. Overall, there was no substantial variation in effect size between the GNB and control arms with regard to the severity of difficulty in swallowing (p = 0.7). Additionally, there were no significant differences observed between the GNB and control groups in terms of postoperative complications endpoints (p > 0.05). This thorough analysis showed that GNB had both statistical and clinical advantages for patients after a tonsillectomy. It was found that GNB was an effective, safe, and straightforward method for managing early postoperative pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04928-w.

Ultrasound-guided distal glossopharyngeal nerve block for post-tonsillectomy pain relief in adults: a prospective randomized study

BACKGROUND

We aimed to evaluate the safety and efficacy of the novel distal approach of ultrasound (US)-guided glossopharyngeal nerve (GPN) block at the pharyngeal wall for enhancing the quality of analgesia in patients undergoing tonsillectomy.

METHODS

Fifty patients, both male and female, between the ages of 21 and 65, categorized as ASA I-II by the American Society of Anesthesiologists (ASA) and who were scheduled for tonsillectomy, were enrolled in the study. Patients were randomly assigned to receive general anesthesia with either bilateral US-guided distal GPN block (GPN group) or no block (control group). The time for first request of analgesics, postoperative pain scores, the total amount of rescue analgesic medication consumed within a 24-hour period, and the occurrence of any adverse events were all noted.

RESULTS

The onset of first analgesic request was significantly prolonged in GPN group than the control group (P=0.013). Pain scores at 30 min, two and six hours postoperative were found to be significantly lower in GPN group than the control group both at rest (adjusted P=0.005, 0.000, and 0.020 respectively) and during swallowing (adjusted P=0.002, 0.000, and 0.015 respectively), with significantly less morphine consumption at 24 hours postoperative in GPN group compared with the control group (P=0.002). No significant postoperative block-related complications were observed.

CONCLUSIONS

In patients having tonsillectomy, pre-emptive application of US-guided distal GPN block at the pharyngeal wall enhanced the quality of analgesia and decreased the need for rescue analgesics with no major adverse effects.

Effects of glossopharyngeal nerve block on pain control after tonsillectomy: a systemic review and meta-analysis

BACKGROUND

We investigated the role of perioperative intraoral glossopharyngeal nerve block to minimize postoperative pain in patients undergoing tonsillectomy through a meta-analysis of the relevant literature.

METHODS

We retrieved eight studies from PubMed, Scopus, Embase, Web of Science, and Cochrane databases up to August 2023. We compared perioperative glossopharyngeal nerve block with a control group, in order to examine postoperative pain, analgesic use, and other postoperative morbidities.

RESULTS

Postoperative pain was significantly reduced at 1-4 h (SMD -1.26, 95% CI [-2.35; -0.17], I2 = 94.7%, P = 0.02) and 5-8 hours (SMD -1.40, 95% CI [-2.47; -0.34], I2 = 96.1%, p = 0.01) in the treatment groups compared to the control group. However, glossopharyngeal nerve block showed no efficacy in reducing pain or use of analgesic drugs after 12 h compared to the control group. The incidences of postoperative bleeding (OR 0.95, 95% CI [0.35; 2.52], I2 = 0.0%), local agent toxicity (OR 4.14, 95% CI [0.44; 38.63], I2 = 0.0%), nasal problems (OR 1.25, 95% CI [0.60; 2.61], I2 = 0.0%), postoperative nausea and vomiting (OR 1.35, 95% CI [0.78; 2.33], I2 = 0.0%), swallowing difficulty (OR 1.61, 95% CI [0.76; 3.42], I2 = 56.0%), and voice change (OR 3.11, 95% CI [0.31; 30.80], I2 = 0.0%) were not significantly different between the treatment and control groups. The treatment group showed higher prevalence of respiratory problems and dry mouth compared to control without statistical significance, but a significant increase in throat discomfort (p = 0.02).

CONCLUSION

Intraoral glossopharyngeal nerve block for tonsillectomy did not significantly impact postoperative pain management and was associated with some adverse effects with increases in respiratory problems, dry mouth, and throat discomfort compared to controls.

Comparative efficacy of topical lidocaine, tetracaine, and articaine for post-tonsillectomy pain management in children: a prospective, placebo-controlled study

BACKGROUND

The most important problem in tonsillectomy is pain in the early postoperative period.

OBJECTIVE

We purposed to compare the effects of lidocaine, tetracaine, and articaine application to the peritonsillar bed on post-tonsillectomy pain in children.

METHODS

The prospective, placebo-controlled study included 80 patients, ages 3-14, who were scheduled for elective tonsillectomy. Patients were randomly divided into four groups. Group 1 received 0.9% NaCl; group 2 received 2% lidocaine; group 3 received 2% tetracaine; and group 4 received 4% articaine to the tonsillary bed for 5 min just after the operation. All patients were evaluated in terms of pain and pain-related adverse events in the postoperative 24 h.

RESULTS

All groups that used local anesthetics had significantly lower pain levels than the control group in the first eight hours (p < .001). Furthermore, the articaine group had a lower pain score than the tetracaine group at the eighth hour (p < .05). The articaine group had a lower pain score at the 16th hour than both the control and tetracaine groups (p < .05). There was no significant difference between the groups at the 24th hour (p > .05).

CONCLUSION AND SIGNIFICANCE

We recommend the immediate application of topical articaine to the tonsillar bed following the procedure to enhance postoperative pain management.

A scoping review of randomized clinical trials for pain management in pediatric tonsillectomy and adenotonsillectomy

Objectives

To examine the volume, topics, and reporting trends in the published literature of randomized clinical trials for pharmacologic pain management of pediatric tonsillectomy and adenotonsillectomy and to identify areas requiring further research.

Data Sources

PubMed (National Library of Medicine and National Institutes of Health), Scopus (Elsevier), CINAHL (EBSCO), and Cochrane Library (Wiley).

Methods

A systematic search of four databases was conducted. Only randomized controlled or comparison trials examining pain improvement with a pharmacologic intervention in pediatric tonsillectomy or adenotonsillectomy were included. Data collected included demographics, pain-related outcomes, sedation scores, nausea/vomiting, postoperative bleeding, types of drug comparisons, modes of administration, timing of administration, and identities of the investigated drugs.

Results

One hundred and eighty-nine studies were included for analysis. Most studies included validated pain scales, with the majority using visual-assisted scales (49.21%). Fewer studies examined pain beyond 24 h postoperation (24.87%), and few studies included a validated sedation scale (12.17%). Studies have compared several different dimensions of pharmacologic treatment, including different drugs, timing of administration, modes of administration, and dosages. Only 23 (12.17%) studies examined medications administered postoperatively, and only 29 (15.34%) studies examined oral medications. Acetaminophen only had four self-comparisons.

Conclusion

Our work provides the first scoping review of pain and pediatric tonsillectomy. With drug safety profiles considered, the literature does not have enough data to determine which treatment regimen provides superior pain control in pediatric tonsillectomy. Even common drugs like acetaminophen and ibuprofen require further research for optimizing the treatment of posttonsillectomy pain. The heterogeneity in study design and comparisons weakens the conclusions of potential systematic reviews and meta-analyses. Future directions include more noninferiority studies of unique comparisons and more studies examining oral medications given postoperatively.

The efficacy and safety of peri-tonsillar administrated agents on pain treatment after pediatric tonsillectomy: A network meta-analysis

OBJECTIVES

We assessed the pain control efficacies and associated morbidities of drugs administered locally (around the tonsils) in pediatric patients undergoing a tonsillectomy.

METHODS

Randomized controlled trials up to April 2022 were retrieved from six databases. The treatment networks featured six interventions (ropivacaine, bupivacaine, levobupivacaine, ketamine, tramadol, and dexamethasone) and a control (placebo). The outcomes were the postoperative pain scores, the time to use of the first analgesic drugs, and postoperative nausea/vomiting. Both pairwise and network meta-analyses were performed.

RESULTS

All treatments controlled pain at 1 h and 1 day postoperatively. Although all agents tended to delay the time to the first analgesic drug, only bupivacaine, dexamethasone, ketamine, and tramadol significantly reduced the need for analgesics. No agent caused significant postoperative nausea or vomiting. The ranking hierarchy revealed that tramadol was superior in terms of pain control 1 h postoperatively, the time to the first analgesic drug, and the number of analgesic doses required; however, it ranked third in terms of operative time.

CONCLUSION

All drugs reduced postoperative pain. Tramadol was optimal in pain control, and dexamethasone also afforded good pain control with low incidences of nausea and vomiting.

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.

The relationship between the level of μ-opioid receptor (μORs) and postoperative analgesic use in patients undergoing septoplasty: a prospective randomized controlled trial

Background

In this study, the μ-Opioid receptor activity was assessed pre-operatively for its association with postoperative pain level and second analgesic requirement in patients undergoing septoplasty.

Methods

In our prospective study, 120 adult patients underwent septoplasty from June 2015 to January 2019 were randomly divided into 2 pre-operative groups. The first group (n = 60) was patients given tramadol (1–2 mg/kg) for post-operative analgesia, and the second group (control group) (n = 60) was initially prescribed only fentanyl (1 μg/ kg-i.v.) in the induction. Acetaminophen with codeine analgesic 325/30 mg (p.o.) was used as an rescue painkiller in the post-operative period. The μ-Opioid receptor activity was investigated in pre-operative blood samples and compared to post-operative pain level and time required for second round of analgesic administration. The visual analogue score (VAS) was used to evaluate the post-operative pain degree (0 no pain; 10 worst pain). The patients’ post-operative VAS scores were evaluated upon arrival to recovery room, and at the 1st, 3rd, 7th, 10th, and 24th hour post-operative period.

Results

Demographic data and peri-operative variables were similar in both study group (p < 0.05).There was no significant difference between the receptor levels in both groups and the mean receptor level was 200.94 ± 15.34 pg/mL (max:489.92 ± 22.36 pg/mL, min: 94.56 ± 11.23 pg/mL).In patients who used tramadol as the levels of μ-Opioid receptors increased, VAS scores of patients and second analgesic use decreased in post-operative period.The VAS scores in patients with higher receptor levels were lower in the recovery room (p < 0.05), 1st (p < 0.05) and 3rd hours (p < 0.05).The VAS scores were lower in the tramadol group compared to the control group (p < 0.05).Number of secondary analgesic requirement was significantly lower in patients of the tramadol group with higher receptor levels compared to the ones with lower receptor (p < 0.05) for arrival at the recovery room and 1st hour. Patients in the tramadol group needed a second pain killer much later than patients in the control group.

Conclusions

Our study demonstrates that patients with higher μOR levels have a higher efficacy of opioid analgesic agents and an lesser need for additional analgesic agents.

Trial registration

This trial was registered retrospectively (The ACTRN: ACTRN12619001652167, registration date: 26/11/2019).

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.

The Effect of Glossopharyngeal Nerve Block on Post-Tonsillectomy Pain of Children; Randomized Controlled Trial

Background

Sensory fibers of the glossopharyngeal nerve supply the tonsillar and peritonsillar areas. Thus, bilateral glossopharyngeal nerve block may alleviate post-tonsillectomy pain and improve postoperative analgesia.

Objectives

The purpose of this clinical trial was to evaluate the effect of glossopharyngeal nerve block on postoperative analgesia in children undergoing adeno-tonsillectomy

Methods

Ninety ASA I-II pediatric patients presented for adeno-tonsillectomy were included in this trial. They were equally divided and randomly assigned to one of two groups: A control group, in which children did not receive a nerve block, and a glossopharyngeal nerve block group, in which children received bilateral glossopharyngeal nerve block after surgery. The postoperative pain score (FLACC score) during rest and swallowing, the time for the first request for rescue analgesia, the total dose consumption of pethidine rescue analgesia, and the incidence of postoperative complications were all assessed. Moreover, response to gag reflex, degree of difficulty in swallowing, and parents’ satisfaction were recorded.

Results

Bilateral glossopharyngeal nerve block in children presented for adeno-tonsillectomy significantly prolonged the time for the first request of rescue analgesia, compared to the control group, reaching 5.833 ± 2.667 hours (P < 0.0001). It also decreased postoperative pethidine consumption to 0.878 ± 0.387 mg/kg (P = 0.0009). Moreover, it significantly decreased the postoperative FLACC score assessed two, four, six, and twelve hours after surgery, during rest and swallowing (P < 0.05). The response to gag reflex and difficulty in swallowing were also significantly decreased (P ≤ 0.0001 and 0.006, respectively). In addition, glossopharyngeal nerve block significantly increased parents’ satisfaction (P = 0.0002), with no significant increase in the incidence of postoperative complications (P > 0.05).

Conclusions

Bilateral glossopharyngeal nerve block in children undergoing adeno-tonsillectomy improved the duration and the quality of postoperative analgesia, decreased swallowing difficulties, and improved parents’ satisfaction.

The effect of flurbiprofen oral spray and ibuprofen vs ibuprofen alone on postoperative tonsillectomy pain: An open, randomised, controlled trial

OBJECTIVE

This prospective clinical study was carried out to evaluate the analgesic efficacy and safety of oral spray form of flurbiprofen in the treatment of postoperative pain in tonsillectomy patients.

STUDY DESIGN

Open, randomised, controlled clinical study.

SETTING

Tertiary care training and research hospital.

PARTICIPANTS

One hundred (53 males, 47 females) with an age range of 18-53 years old (mean 27.4 ± 9.3 SD) undergoing tonsillectomy were enrolled in this prospective controlled study.

MAIN OUTCOME MEASURES

Patients receiving oral ibuprofen and flurbiprofen as spray form were enrolled as study group (53), whereas patients receiving only oral ibuprofen were enrolled as control group (47) in postoperative period. Postoperative pain was evaluated through visual analogue scale on 12th hour, first, third and seventh days after surgery.

RESULTS

The mean maximal pain score of patients who have received flurbiprofen spray and ibuprofen was 3.36 ± 1.93 SD that was statistically lower than the mean maximal pain score of patients who were medicated with only ibuprofen which was 4.06 ± 1.29 SD on postoperative seventh day (P = .013).

CONCLUSION

This study revealed that addition of flurbiprofen spray to oral ibuprofen is effective in the management of postoperative pain in tonsillectomy patients with no notable complications.

The Efficacy of Levobupivacaine Hydrochloride-Dexamethasone Infiltration for Post-Tonsillectomy Pain in Adults

OBJECTIVE

The aim of the study is to evaluate the efficacy of peritonsillar infiltration of a levobupivacaine hydrochloride and dexamethasone combination for post-tonsillectomy pain in adult patients.

METHODS

A total of 40 patients were included in this double-blind, randomized, and placebo-controlled study. The patients were equally randomized into 2 groups by means of sealed envelopes. The study group (SG) received peritonsillar levobupivacaine hydrochloride and dexamethasone infiltration and the control group (CG) received peritonsillar saline infiltration. Pain scores at the second, fourth, eighth, 12th, 16th, and 24th hours and the second to seventh days after operation were recorded by the patients in each group using a visual analog scale. Duration of surgery and the total amount of blood loss during the surgery were also recorded for each patient.

RESULTS

All pain scores in the SG were lower than those in the CG; however, the difference was significant at the second, 12th, and 16th hours, and the second and third day (P < 0.05). Postoperative morbidity parameters, including otalgia, nausea, vomiting, fever, halitosis, and bleeding were similar between the 2 groups. Total amount of analgesic consumption in the SG was significantly lower than in the CG on each day of the week after tonsillectomy.

CONCLUSIONS

Peritonsillar infiltration of a levobupivacaine hydrochloride and dexamethasone combination may provide pain reduction and decrease analgesic consumption in the postoperative period after adult tonsillectomy.

Oral Flurbiprofen Spray for Posttonsillectomy Pain

OBJECTIVE

Tonsillectomy is still one of the most common surgical procedures, but there exists no standard guideline for pain management after tonsillectomy. Our aim is to determine whether oral spray of flurbiprofen reduces pain and has an influence on other morbid outcomes following tonsillectomy.

STUDY DESIGN

Prospective, double-blind, randomized, placebo controlled.

SETTING

Patients at Ataturk Training and Research Hospital, Ankara, Turkey.

SUBJECTS AND METHODS

This study was performed on 84 patients (45 in flurbiprofen group, 39 in placebo group) who underwent tonsillectomy. The patients were randomly chosen, and each used oral spray of flurbiprofen 3 times daily or placebo solution at the same regimen. Efficacy was assessed by changes in Numeric Pain Rating Scale. Data were collected at postoperative days 1, 3, 5, and 7 for pain, bleeding, and healing. Data for Mallampati scores were also collected.

RESULTS

There were no significant difference between groups with respect to the demographic data. The flurbiprofen group had statistically significant lower pain scores at days 1, 3, 5, and 7 (P = .000, P = .002, P = .001, P = .000, respectively). On days 3 and 7, pain scores were significantly different between different Mallampati groups (P = .049, P = .015, respectively). The flurbiprofen group required less analgesic than the placebo group during the study period on days 1, 3, 5, and 7 (P = .001, P = .001, P = .03, P = .001, respectively). Healing and side effects were not significantly different between the groups.

CONCLUSION

In this study, topical use of flurbiprofen may reduce posttonsillectomy pain without any evidence of additional complications.

The 100 Most Cited Turkish Papers in the Otorhinolaryngology Journals of Web of Science

Objective

The aim of the study was to analyze the 100 most cited publications with Turkish origin in the Web of Science Otorhinolaryngology (ORL) journals.

Methods

The Web of Science database was searched in terms of citations for publications originating from Turkey in ORL journals since 1983. After the identification of the 100 most cited articles, analysis was performed for the first author, institution, city, publication type, subject related to subspecialty, and journals having the most cited articles. Moreover, the number of ORL publications and citations of countries was determined in descending order using the same database.

Results

A total of 3948 ORL articles with Turkish origin was identified. The number of citations was 181 for the first and 28 for the last in the 100 most cited articles. As there was more than one article with 28 citations, 101 articles were analyzed. The number of the articles was 76, 22, and 3 for the university, education/research, and state hospitals, respectively. Hacettepe University, Ankara Numune Hospital, and Gazi University were the three leading institutions having the most cited articles, and Ankara was the first city. While 98 of 101 articles were original research, the number of case reports and review articles were 2 and 1, respectively. Thirty-five articles were related to otology, 23 to pediatric ORL, 20 to rhinology and head and neck surgery, and 3 to facial plastic surgery. Laryngoscope, Otolaryngology-Head and Neck Surgery, and International Journal of Pediatric Otorhinolaryngology were the leading 3 journals with the most cited articles coming from Turkey. The evaluation of countries revealed that Turkey was among the first 10 countries in terms of number of ORL articles but fell behind for the number of citations.

Conclusion

This bibliometric study is the first one regarding the contribution of Turkish authors and institutions to ORL literature. Similar studies might be periodically repeated to determine national development in the field of ORL and place of Turkey in the world.

Comparison of local and intravenous dexamethasone for postoperative pain and recovery after tonsillectomy

OBJECTIVE

To compare local infiltration of dexamethasone to intravenous injection for postoperative pain and recovery after tonsillectomy.

STUDY DESIGN

Prospective, randomized study.

SETTING

Second Affiliated Hospital of Harbin Medical University.

SUBJECTS AND METHODS

Children (n=240, American Society of Anesthesiologists [ASA] classes I-II, aged 5-10 y) scheduled for tonsillectomy were randomly and equally assigned to 3 groups: DEX-IV, for intravenous injection of dexamethasone (0.5 mg/kg, maximum dose 24 mg); DEX-INF, given the same amount of dexamethasone by local infiltration to the upper middle and lower poles of the tonsils; and a control group not given dexamethasone. Postoperative pain was scored at intervals from 30 minutes to 24 hours. The time to first administration of analgesic and average consumption of analgesic, times to first oral water and solid food intake, and incidence rates of nausea and vomiting were evaluated.

RESULTS

From postoperative 1 to 16 hours, the DEX-INF group had significantly lower pain scores than did the DEX-IV group, and the time to first analgesic and average consumption of analgesic were also significantly lower. The times to first oral water and food intake in the DEX-INF group were significantly shorter than in the DEX-IV group. The incidence of nausea and vomiting in the DEX-INF group was higher than that of the DEX-IV group.

CONCLUSION

Local infiltration of dexamethasone was more effective than systemic administration to decrease pain and time to food intake, but the antiemetic effect was less.

CLINICAL TRIALS REGISTRATION NUMBER

ChiCTR-TRC-13003535.

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.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2010 and previously updated in 2011.Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period.

OBJECTIVES

To assess the effects of oral rinses, mouthwashes and sprays in improving recovery 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; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 4 July 2013.

SELECTION CRITERIA

We included randomised controlled trials in which oral rinses, mouthwashes and sprays, used pre- and postoperatively, have been compared with placebo in adults or children undergoing tonsillectomy, with or without adenoidectomy.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently.

MAIN RESULTS

We included seven trials (593 participants; 397 children and 196 adults). The period of follow-up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. The risk of bias was high in most of the included trials. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage.

AUTHORS' CONCLUSIONS

Poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data.

Pre-emptive triple analgesia protocol for tonsillectomy pain control in children: double-blind, randomised, controlled, clinical trial

Introduction:

This double-blind, controlled, parallel-group study was designed to determine the efficacy of pre-emptive triple analgesia for paediatric post-tonsillectomy pain management.

Materials and methods:

One hundred and thirty-five children were randomised into two groups: pre-emptive triple analgesia (n = 55) and control (n = 80). Pain was assessed using a visual analogue scale (in hospital) and the Parent's Postoperative Pain Measure (at home), and scores recorded.

Results:

Visual analogue scale scores on awakening and for 6 hours post-surgery were significantly better in the study group than the control group (p < 0.05). The Parent's Postoperative Pain Measure scores of control group children were significantly higher within the first 3 post-operative days (p = 0.000), with a greater percentage of children experiencing significant pain and requiring more analgesia.

Conclusion:

The proposed multimodal, pre-emptive analgesia protocol for paediatric post-tonsillectomy pain results in less post-operative pain, both in hospital or at home.

The effects of levobupivacaine infiltration on post-tonsillectomy pain relief in adults: a single-blinded, randomized, and controlled clinical study

The aim of this prospective single-blinded and controlled study is to evaluate the efficacy of levobupivacaine infiltration on post-tonsillectomy pain relief in adults. The study was conducted with 40 adult patients who underwent tonsillectomy. These patients were randomized in either study group (SG) who received levobupivacaine infiltration to peritonsillary fossae prior to surgery or control group (CG) with no medication. After surgery, all the patients were queried for pain scores by visual analog scale. In addition, the volume of intraoperative bleeding, the duration of operation, the severity of postoperative complications, and the amount of analgesic requirement were the other outcome measures of this study. There were significant differences between groups regarding pain scores for the first 24 h in favor of SG. The analgesic requirement was also significantly lower in SG (p = 0.009). Although there was a sustained decrement at pain score during first 24 h for SG, however, the change from baseline score (immediate score) for each time interval revealed no significance compared to CG. In addition, the duration of operation and the volume of intraoperative bleeding were similar (p = 0.64 and p = 0.165). In conclusion, preincisional infiltration of levobupivacaine is a safe and reliable method for post-tonsillectomy pain reduction in adults. However, more in-depth, double-blinded and placebo controlled studies are required to elucidate its long term benefits.

Dexmedetomidine reduces emergence agitation after tonsillectomy in children by sevoflurane anesthesia: a case-control study

OBJECTIVE

To evaluate the efficacy and safety of dexmedetomidine for emergence agitation after tonsillectomy in children.

METHODS

120 ASA physical status I and II children, aged 5-14 years, undergoing anesthesia for tonsillectomy, were randomly divided into 3 groups: Placebo group, the low dexmedetomidine concentration group and the high dexmedetomidine concentration group. Before the entrance of the operating room (OR), all of the children received intravenous injection 40 μg kg(-1) midazolam to reduce anxiety at first, and then dexmedetomidine was given intravenously at an initial loading dose of 0.5 μg kg(-1) or 1 μg/kg over a 10-min period via a computer controlled infusion pump followed by a maintenance infusion of 0.2 μg kg(-1)h(-1) or 0.4 μg kg(-1)h(-1)over the surgery. The heart rate, SpO(2) and mean arterial blood pressure were recorded for each patient in both operation room and PACU. The designated time points: at the start of the anesthetic induction, at the discontinuation of inhalational agents, at first opening of eyes, at time to remove endotracheal tube were recorded. After patient arrival at the PACU, VAS score, RSS, the occurrence of emergence agitation were recorded every 5 min for the first 30 min and every 10 min for the next 30 min after endotracheal tube was removed.

RESULTS

There was significant difference in the incidence of emergence agitation between Placebo group and the high concentration group when endotracheal tube was removed (P<0.05). There was significant difference in the VAS pain scores and in the RSS between three groups at the time of extubation, as well as 5 min and 10 min after extubation (P<0.05).

CONCLUSIONS

Dexmedetomidine appears to be safe and effective to reduce the incidence of early emergence agitation in children after tonsillectomy. Initial loading dose of 1.0 μg kg(-1) followed by a maintenance infusion of 0.4 μg kg(-1)h(-1) is better choice for children received tonsillectomy.

Comparison of pre-emptive tonsillar lodge infiltration with ropivacaine versus intravenous tramadol in pediatric tonsillectomies: a randomized placebo-controlled study

OBJECTIVE

To investigate the placebo controlled effect of pre-emptive local infiltration of ropivacaine and intravenous tramadol in postoperative pain and nausea-vomiting in pediatric tonsillectomy cases.

METHODS

90 children at ASA I-II physical status, who are between 2 and 9 years old, underwent tonsillectomy were included to the study. Patients were randomized into one of three study groups. Group I was i.v. saline group (placebo group), Group II was preemptive 1.5 ml 0.75% ropivakain to the tonsil lodge and Group III was preemptive 1mg/kg i.v. tramadol. Hemodynamic parameters and synchronized Maunuksela pain scores were evaluated in the post anesthetic care unit.

RESULTS

There was no difference in age, weight, sex and hemodynamic parameters of children included to the study groups. Postoperative nausea vomiting was significantly lower in Group II and pain scores at resting and swallowing are significantly lower than the other study groups. Maunuksela pain scores at 2nd, 3rd, 6th and 9th hours while resting were significantly lower in Group II compared with Groups I and III (p<0.001). The comparison of scores between groups I and III were similar. Maunuksela pain scores during swallowing were significantly lower in Group II compared with Group I and III at 2nd, 3rd, 6th, 9th, 12th, 21st and 24th hours postoperatively (p<0.001). While comparing Maunuksela pain scores of Groups I and III, significantly lower scores are determined at 2nd and 24th hours in Group III (p<0.001). Analgesic needs were significantly low in Group II at postoperative period (150 ± 30 mg paracetamol) (p<0.05). It was similar in Groups I and III (Group I: 400 ± 40 mg, Group III: 360 ± 40 mg paracetamol).

CONCLUSION

This study showed that peritonsillar ropivacaine infiltration might produce an effective postoperative analgesia probably due to a preventing effect on sensitization of the pain pathways.

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.

Use of intravenous steroids at induction of anesthesia for septoplasty to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial

To determine the effectiveness of dexamethasone to reduce pain, nausea and vomiting after septoplasty. Study is a prospective double-blind randomized controlled trial. A total of 90 patients were enrolled and received an either of dexamethasone or placebo in the induction of anesthesia. The patients were asked to note the level of pain on the visual analogue scale in the first 24 h after surgery. They also had to record their severity of nausea and number of vomiting attacks. There were statistically significant differences between the two groups for the level of pain noted on the visual analogue scale. The severity of nausea was lower after treatment with dexamethasone but the difference between two groups was not significant. There was also a significant decrease in the number of vomiting attacks in patients treated with dexamethasone. A single dose of 8 mg of dexamethasone, given intravenously, at induction of anesthesia for septoplasty significantly decreased the pain, post-operative nausea and vomiting for the day of operation.

Steroids for improving recovery following tonsillectomy in children

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2003.Tonsillectomy continues to be one of the most common surgical procedures performed worldwide. Despite advances in anesthetic and surgical techniques, post-tonsillectomy morbidity remains a significant clinical problem.

OBJECTIVES

To assess the clinical efficacy of a single intraoperative dose of dexamethasone in reducing post-tonsillectomy morbidity.

SEARCH STRATEGY

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; ISRCTN; and additional sources for published and unpublished trials. The date of the most recent search was 29 October 2010, following a previous search in September 2002.

SELECTION CRITERIA

Randomized, double-blind, placebo-controlled trials of a single dose of intravenous, intraoperative corticosteroid for pediatric patients (age < 18 years) who underwent tonsillectomy or adenotonsillectomy.

DATA COLLECTION AND ANALYSIS

The first author extracted data regarding the primary outcome measures and measurement tools from the published studies. The first author also recorded data regarding study design, patient ages, procedures performed, dose of corticosteroid and method of delivery, as well as methodological quality. When data were missing from the original publications, we contacted the authors for more information. We performed data analysis with a random-effects model, using the RevMan 5.1 software developed by the Cochrane Collaboration.

MAIN RESULTS

We included 19 studies (1756 participants). We selected only randomized, placebo-controlled, double-blinded studies to minimize inclusion of poor quality studies. However, the risk of bias in the included studies was not formally assessed. Children receiving a single intraoperative dose of dexamethasone (dose range = 0.15 to 1.0 mg/kg) were half as likely to vomit in the first 24 hours compared to children receiving placebo (risk ratio (RR) 0.49; 95% confidence interval (CI) 0.41 to 0.58; P < 0.00001). Routine use in five children would be expected to result in one less patient experiencing post-tonsillectomy emesis (risk difference (RD) -0.24; 95% CI -0.32 to -0.15; P < 0.00001). Children receiving dexamethasone were also more likely to advance to a soft/solid diet on post-tonsillectomy day one (RR 1.45; 95% CI 1.15 to 1.83; P = 0.001) than those receiving placebo. Finally, postoperative pain was improved in children receiving dexamethasone as measured by a visual analog scale (VAS, 0 to 10) (MD -1.07; 95% CI -1.73 to -0.41; P = 0.001), which correlates clinically to a reduction in pain (on a VAS of 0 to 10) from 4.72 to 3.65. No adverse events were noted in the included studies.

AUTHORS' CONCLUSIONS

The evidence suggests that a single intravenous dose of dexamethasone is an effective, safe and inexpensive treatment for reducing morbidity from pediatric tonsillectomy.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2010.Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period.

OBJECTIVES

To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy.

SEARCH STRATEGY

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 22 April 2011.

SELECTION CRITERIA

We included randomised controlled trials in which mouthwashes, used pre- and postoperatively, have been compared with placebo.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently.

MAIN RESULTS

We included six trials (528 participants; 397 children and 131 adults). The period of follow up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain but only until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage.

AUTHORS' CONCLUSIONS

The risk of bias was high in most of the included trials and poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments, and the quality of reporting and subsequent analysis of the data.

Comparison of peritonsillar levobupivacaine and bupivacaine infiltration for post-tonsillectomy pain relief in children: placebo-controlled clinical study

OBJECTIVES

To compare the effects of preincisional peritonsillar infiltration of levobupivacaine and bupivacaine on post-tonsillectomy pain in children.

METHODS

Sixty children undergoing elective tonsillectomy or adenotonsillectomy were randomly allocated into three groups before tonsillectomy: peritonsillar infiltrations with 0.25% levobupivacaine with 1:200,000 epinephrine (group levobupivacaine, n=20), 0.25% bupivacaine with 1:200,000 epinephrine (group bupivacaine, n=20), and normal saline (group saline, n=20) were applied. Pain was evaluated by using a modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS). Choice of additional analgesic was acetaminophen for all patients.

RESULTS

mCHEOPS values at 0th (immediately) and 30th minute after arrival the PACU were lower in both the local anesthetics groups than the saline group (p<0.001, p<0.01 for the group levobupivacaine; p<0.001, p<0.05 for the group bupivacaine, respectively). In addition, mCHEOPS values at 1st hour in the ward was lower in the group bupivacaine when compared to the group saline (p<0.05). Analgesic requirements and the time to first analgesia required, were also significantly different between the local anesthetic and saline groups (p<0.05 for both local anesthetics groups). Time to first mobilization was shorter in both local anesthetic groups when compared to the saline group (p<0.05 for both local anesthetic groups).

CONCLUSION

Preincisional peritonsillar infiltration with levobupivacaine or bupivacaine before tonsillectomy, are effective than saline, in reducing early post-tonsillectomy pain, where as bupivacaine had slightly longer effect. Compared to saline, with both anesthetic infiltrations, lesser medication for analgesia is required. The clinical trial registration number (Research Ethics Committee of Medical Faculty, Uludag University): 2008-4/36, 19 February 2008.

Topical bupivacaine compared to lidocaine with epinephrine for post-tonsillectomy pain relief in children: a randomized controlled study

OBJECTIVE

To compare the topical administration of bupivacaine hydrochloride, lidocaine hydrochloride with epinephrine and saline in alleviating post tonsillectomy pain.

STUDY DESIGN

A double-blind prospective randomized controlled clinical study.

METHODS

Between November 2008 and March 2009, 60 patients (32 males and 28 females) between ages of 1.5 and 15 years were recruited into the study. After informed consent was obtained from the parents, patients, admitted for tonsillectomy, were randomized into three groups using sealed envelops. Group 1 (20 patients, mean age 5.2±1.7) received topical lidocaine hydrochloride (20 mg/ml) with 0.00125% epinephrine. Group 2 (20 patients, mean age 6±3.7) received topical 0.5% bupivacaine hydrochloride and group 3 (20 patients, mean age 6.7±3.6) received topical saline.

RESULTS

The post-operative pain scores at 1h were similar among the groups (p=0.29). Pain scores in bupivacaine hydrochloride group were significantly lesser than the saline group at 5th, 13th, 17th and 21st hours, until the sixth day (p<0.017). Moreover, pain scores of bupivacaine hydrochloride group were superior to lidocaine hydrochloride group starting at 17 h, until fourth day (p<0.017). Pain scores of lidocaine hydrochloride group were lesser than saline group in the first and fifth days (p<0.017), whereas, there was no significant difference at other times.

CONCLUSION

Topical administration of bupivacaine hydrochloride proved to provide more efficient pain control than both saline and lidocaine without any drug related complication.

Does preincisional injection of levobupivacaine with epinephrine have any benefits for children undergoing tonsillectomy? An intraindividual evaluation

OBJECTIVE

To evaluate the effects of peritonsillar injection of levobupivacaine with epinephrine in children undergoing adenotonsillectomy, through an intraindividual study.

PATIENTS AND METHODS

20 children (age 6-13 years) undergoing elective tonsillectomy with or without adenoidectomy were enrolled in this prospective, randomized, intraindividual trial. After entubation and just prior to incision, 3 ml of 0.25% levobupivacaine with epinephrine was injected into one peritonsillar region while 0.9% saline was being used for the contralateral side. Amount of intraoperative blood loss, duration of tonsillectomy, postoperative pain, otalgia and hemorrhage were assessed for each side separately. Visual analog scale was used for postoperative pain assessment. Heart rate and mean arterial pressure during and after operation were also observed. The follow-up period after surgery was 10 days.

RESULTS

Median visual analog scale values for the levobupivacaine with epinephrine injected side was significantly lower than the saline injected side, during the first postoperative 16h (p<0.05). There were also significant differences between the intraoperative blood losses of the two sides (p<0.05). However; no significant differences were observed with respect to duration of surgery, postoperative otalgia and hemorrhage (p>0.05).

CONCLUSION

Preincisional injection of levobupivacaine with epinephrine decreases early postoperative pain and intraoperative blood loss as well.

Bupivacaine versus normal saline for relief of post-adenotonsillectomy pain in children: a meta-analysis

OBJECTIVE

A meta-analysis was performed to explore the role of peri-operative bupivacaine infiltration in the relief of pain in adenotonsillectomy.

METHODS

Data from Medline, EMBase, Springer and the Cochrane Collaboration database were searched. Reference lists from identified publications were scanned. RevMan 5.0 software was used for statistical analysis.

RESULTS

7 random controlled tests (a total of 286 cases) were included. Pain intensity was evaluated by VAS score or Cheops score. The pain of group bupivacaine (Group B) was less severe than group placebo (Group P). Analgesic requirement of Group B was less than Group P. Nevertheless the difference of complication between bupivacaine and placebo had no statistical difference.

CONCLUSION

Bupivacaine infiltration is a safe and effective method for relief of pediatric post-adenotonsillectomy pain.

Oral rinses, mouthwashes and sprays for improving recovery following tonsillectomy

BACKGROUND

Tonsillectomy is the surgical removal of lymphoid tissue, the palatine tonsil, which is located at the back of the throat. It is still commonly performed for patients who have recurrent bouts of acute tonsillitis. Although tonsillectomy is considered a fairly minor procedure, pain and bleeding are two of the most common complications; either may delay recovery and can on occasion lead to hospital readmission. Postoperative tonsillectomy medication should provide an adequate reduction in morbidity while minimising side effects, therefore topical agents would seem to be an ideal, safe option. A number of mouthwashes and topical sprays are available which offer pain relief or can help to reduce bleeding in the immediate postoperative period.

OBJECTIVES

To assess the effects of oral rinses, mouthwashes and sprays in improving recovery following tonsillectomy.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL, PubMed; EMBASE; CINAHL; AMED; ISI Web of Science; BIOSIS Previews; CAB Abstracts; LILACS; KoreaMed; IndMed; PakMediNet; China National Knowledge Infrastructure; NRR (National Research Register) Archive; mRCT (the metaRegister of Controlled Trials) and Google to March 2009.

SELECTION CRITERIA

We included randomised controlled trials in which mouthwashes, used pre- and postoperatively, have been compared with placebo.

DATA COLLECTION AND ANALYSIS

Two review authors selected trials for inclusion, assessed the risk of bias and extracted data independently.

MAIN RESULTS

We included six trials (528 participants; 397 children and 131 adults). The period of follow up ranged from 24 hours to two weeks. Few of the trials provided reliable data for the pre-specified primary outcomes and none for the secondary outcomes. Lidocaine spray appeared to be more effective than saline spray at reducing the severity of pain but only until the third postoperative day. A small number of participants experienced a burning or stinging sensation with benzydamine spray but not sufficient to discontinue usage.

AUTHORS' CONCLUSIONS

The risk of bias was high in most of the included trials and poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made. Future trials should be well-constructed and pay more attention to the methods used to assess outcomes, the timing of the assessments and the quality of reporting and subsequent analysis of the data.

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.

[Steroids for reduction of morbidity following tonsillectomy]

BACKGROUND

Of the morbidities that follow tonsillectomy, nausea and vomiting, fever, pain and inadequate oral intake are the most commonly encountered. The incidence of postoperative nausea and vomiting (PONV) has been reported as between 40% and 85%. In children, the risk of dehydration is increased owing to the delay in oral intake of fluids in the early postoperative period. In efforts to reduce postoperative morbidity, numerous modifications and adjuncts to the surgical procedure have been suggested, including the use of steroids.

PATIENTS AND METHODS

Reduction in PONV, pain and early return to a normal diet were studied as separate end-points in a review of the current literature.

RESULTS

A total of 31 studies matched our search criteria and involved paediatric and adult patient populations. Only 15 studies evaluated pain, PONV and diet. The lack of standardised surgical and anaesthetic techniques and the variations in length of follow-up, concentration of steroids administered and patient age distribution weaken the impact of the results recorded in several studies. However, two-thirds show that a single intravenous dose of dexamethasone reduces pain, although this was limited to the early postoperative period. Moreover, 15 studies confirmed a beneficial effect of dexamethasone on both PONV and early oral intake.

CONCLUSIONS

Preoperative administration of a single dose of dexamethasone to reduce postoperative morbidity resulting from tonsillectomy is supported by several studies. Adverse events have never been reported. However, further studies are warranted to determine the optimum dose required and the effect in adult tonsillectomy patients. In addition, the data should be based on standardised surgical and anaesthetic techniques to allow reliable evaluation of the significance of all outcome measures.

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.

Peritonsillar infiltration with bupivacaine and pethidine for relief of post-tonsillectomy pain: a randomised double-blind study

Previous studies of infiltration of local anaesthetics in children undergoing tonsillectomy resulted in conflicting results. The aim of this study was to evaluate the effect of the peritonsillar injection of bupivacaine and pethidine on postoperative pain in children undergoing snare-dissection tonsillectomy. In a double-blind study, 80 children (aged 7-15 years) were randomly divided into two groups receiving peritonsillar injection of either bupivacaine (1 mg x kg(-1)) and pethidine (1 mg x kg(-1)) in adrenaline 1:200,000 (treatment group) or an equivalent volume of saline (placebo group) pre-operatively. The time needed for first demand of analgesia and analgesic consumption to reduce the visual analogue scale (VAS) for resting throat pain to < or = 30, the VAS for pain on swallowing, drinking liquid and eating a soft diet, incidence of nausea and vomiting, and the need for rescue anti-emetics in the first 24 h after operation were compared in both groups. The combination of bupivacaine and pethidine could significantly decrease the consumption of analgesics for resting pain at 4, 6, 8, 12, and 24 h after operation but did not reduce pain on swallowing, drinking liquid and eating a soft diet. The times to demand of first dose of analgesic and to first oral intake were not significantly different. The overall satisfaction of patients in relation to relief of postoperative pain was not significantly different between the two groups. Although peritonsillar injection of pethidine and bupivacaine in children reduces the analgesic consumption, it does not affect the dynamic pain state in the first 24 h after snare-dissection tonsillectomy.

The effects of glossopharyngeal nerve block on postoperative pain relief after tonsillectomy: the importance of the extent of obtunded gag reflex as a clinical indicator

BACKGROUND

We evaluated the efficacy of glossopharyngeal nerve block (GNB) for the control of post-tonsillectomy pain in adult patients, and correlated the extent of obtunded gag reflex as a clinical indicator of GNB with the extent of pain relief.

METHODS

Seventy-five patients undergoing tonsillectomy received bilateral GNB with 0.75% ropivacaine with epinephrine (Group R), 0.5% bupivacaine with epinephrine (Group B) at the end of the operation, or no intervention (Group C). To evaluate the effects of GNB, we assessed throat pain (100 mm visual analog scale) and severity of gag reflex response 0.5, 8, and 24 h after surgery.

RESULTS

In the immediate postoperative period, pain scores at rest and when swallowing in Groups R and B were significantly lower than those in Group C (21 +/- 17 and 23 +/- 13 vs 42 +/- 16, 28 +/- 22 and 32 +/- 19 vs 62 +/- 14, P < 0.001). The analgesic effect of GNB was strongly correlated with the extent of obtunded gag reflex (P < 0.01).

CONCLUSIONS

GNB is a useful method for the palliation of post-tonsillectomy pain. An obtunded gag reflex response may be a clinical indicator for analgesia from GNB.

Can postoperative pains following tonsillectomy be relieved by honey? A prospective, randomized, placebo controlled preliminary study

OBJECTIVE

To compare the effectiveness of acetaminophen versus acetaminophen-plus-honey following pediatric tonsillectomy and adenoidectomy.

DESIGN

Prospective, randomized, and placebo controlled clinical trial.

SETTING

Tertiary care facility in Ankara, Turkey.

PATIENTS

Sixty consecutive tonsillectomy patients randomized to two groups.

INTERVENTIONS

The acetaminophen group was treated with antibiotics (amoxicillin-clavulonic acid), acetaminophen and placebo, acetaminophen-plus-honey group was treated with antibiotics (amoxicillin-clavulonic acid), acetaminophen, and honey. Visual analogue scale (VAS) was applied for subjective assessment of postoperative pains, while the number of painkillers taken daily and awakening at night due to pain were used for objective assessment. The amount of epithelization was used for assessment of tonsillary fossa recovery.

OUTCOME MEASURES

The difference between acetaminophen and acetaminophen-plus-honey groups was statistically significant both in terms of VAS and number of painkillers taken within the first 2 postoperative days (p<0.001). Although there was no statistically significant difference between groups regarding the VAS scores on the 3rd postoperative day and after, the number of painkillers taken differed significantly until the 8th postoperative day (p<0.001 for first 7 postoperative days; p=0.003 for 8th day). No significant difference was found between groups regarding the number of awakening at night (p=0.36). Tonsillary fossa epithelization was more rapid in the acetaminophen-plus-honey group (p<0.001).

CONCLUSION

Oral administration of honey following pediatric tonsillectomy may relieve postoperative pain and may decrease the need for analgesics. Prospective, randomized, and double-blind studies should further be conducted in order to confirm the data obtained in this study and develop a standard protocol to achieve maximum clinical efficiency.

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.