Post-tonsillectomy Analgesia Research Articles

Ultrasound-Guided Selective Glossopharyngeal and Maxillary Nerve Blocks for Analgesia After Tonsillectomy: A Pilot Study.

Purpose Postoperative pain management methods for tonsillectomy commonly include the use of opioids, non-steroidal anti-inflammatory drugs, and acetaminophen. However, some patients report pain despite the use of these medications. In recent years, ultrasound-guided selective glossopharyngeal nerve block (UGSGNB) and ultrasound-guided maxillary nerve block (UGMNB) have been reported to be effective for analgesia post-tonsillectomy. We retrospectively analyzed the effects of UGSGNB and UGMNB in the perioperative management of patients who underwent tonsillectomy under general anesthesia. Methods This retrospective study evaluated adults (18-61 years old) who had received general anesthesia for tonsillectomy. The control group comprised 25 patients who received general anesthesia using the standard protocol, and the nerve block group comprised 10 patients who also received additional UGGNB and UGMNB. Results While these nerve blocks may have contributed to improving the postoperative food intake, they did not reduce the frequency of postoperative analgesia used. Improved dietary intake after UGSGNB and UGMNB could be advantageous for postoperative recovery. Conclusion Further research with a larger number of cases and prospective intervention studies are necessary to determine the effects of combining UGSGNB and UGMNB for post-tonsillectomy analgesia.

Comparative Analysis of Nebulized Versus Intravenous Fentanyl for Pain Control After Tonsillectomy: A Double-Blind, Randomized, Controlled Trial.

Effective posttonsillectomy analgesia is crucial for patient comfort and recovery. Fentanyl, notable for its potency, rapid action, and lipophilicity, has been successfully used in various procedures through multiple administration routes. However, the use of its nebulized form for posttonsillectomy pain has not been extensively explored. This study sought to compare the analgesic efficacy, onset time, and complications between nebulized and intravenous fentanyl in posttonsillectomy patients. In this randomized controlled trial, adult patients who underwent tonsillectomy were assigned to either an intravenous fentanyl group (1 mcg/kg) or a nebulized fentanyl group (4 mcg/kg). In both groups, fentanyl was administered when pain scores exceeded three. Pain levels were monitored every 5 minutes until they fell below four. The study also recorded the duration until the next analgesia request and noted complications (such as respiratory depression, bradycardia, chest tightness, drowsiness, nausea, pruritus, sweating, and flushing) within 24 hours. Patient exclusions were based on predetermined criteria. From an initial cohort of 59 patients, 22 in the intravenous group and 27 in the nebulizer group were eligible for analysis after applying the exclusion criteria. The nebulizer group exhibited a significantly prolonged period before the next analgesia request, with a median of 683.5 minutes (interquartile range 260-1440), in contrast to the 326.7 minutes (145.0-504.7) observed in the intravenous group (P = .009). The time to achieve a pain score less than 4 and the incidence of side effects did not differ significantly between the groups. Nebulized fentanyl provided a longer duration of analgesia than intravenous fentanyl in posttonsillectomy pain management, with similar onset times and side effect profiles. These findings underscore the potential of nebulized fentanyl as an effective alternative for pain control in posttonsillectomy patients.

Efficacy of peritonsillar infiltration with dexmedetomidine versus tramadol in comparison to placebo for pain control and sedation after tonsillectomy in pediatric patients: A randomized clinical trial.

This article aimed to assess the efficacy of peritonsillar infiltration with dexmedetomidine-ropivacaine versus tramadol-ropivacaine for pain control and sedation after tonsillectomy in pediatric patients. This double-blind clinical trial recruited 99 eligible children (4-8 years old) undergoing tonsillectomy and assigned to three block-randomized groups, receiving dexmedetomidine-ropivacaine (group A), tramadol-ropivacaine (group B), or placebo-ropivacaine (group C). The vital signs included blood pressure, heart rate, and SaO2 before anesthesia induction, during surgery at regular intervals until 24 h after surgery. The duration of surgery and recovery, complications, and analgesic consumption were recorded and pain scores were measured by Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Oucher scales as well as sedation scores by the Wilson sedation scale. Data were analyzed within SPSS 20 at a significance level of 0.05. The lowest pain scores were measured by the CHEOPS scale in the dexmedetomidine-ropivacaine group (P < 0.05). Statistically significant difference was observed in the CHEOPS pain score between the first two groups at 30 min, 1 h, 2 h, and 4 h after surgery (P < 0.01). The differences were revealed in the Oucher pain assessments among all groups from the time of recovery to four postoperative hours (P < 0.05), with the lowest in the dexmedetomidine-ropivacaine group whose sedation score was greater during recovery and 5 min after surgery (P < 0.05). Subjects in tramadol group had six cases of dizziness and nausea, while no side effects were observed in two other groups (P < 0.05). Only seven participants receiving dexmedetomidine required acetaminophen, but 29 in the tramadol group and all in the placebo group demanded to receive acetaminophen (P = 0.001). The authors concluded that dexmedetomidine as an adjuvant to ropivacaine has better performance in local infiltration for intra- and post-tonsillectomy analgesia and postoperative sedation, without any special side effects (like the placebo group), and that it hence is recommended to be used for local infiltration during tonsillectomy.

The interest of Ketamine as an adjuvant to fentanyl in post-tonsillectomy analgesia in children: a randomized controlled trial

The interest of Ketamine as an adjuvant to fentanyl in post-tonsillectomy analgesia in children: a randomized controlled trial

286 Two-Cycle Audit on Post-Tonsillectomy Analgesia

Abstract Objective To assess whether children undergoing tonsillectomy were receiving adequate analgesia postoperatively and comparison made against national standards. Implementation of new ibuprofen dosage guidance, reducing opioid prescribing, and assessment of whether this impacts re-admission rates for post tonsillectomy pain and bleeding. Method Retrospective audit of tonsillectomies performed over a 5-month period in 2021 and prospective audit over the same time period in 2022, with new ibuprofen prescribing guidelines (7.5mg/kg QDS compared with 5mg/kg TDS previously) and effect on reduced opioid prescribing. Results There were approximately 110 tonsillectomies performed in each cycle. For the first retrospective cycle, 95% were prescribed inadequate ibuprofen, with a mean dose of 5.5mg/kg. All patients who were readmitted with pain/haemorrhage had ibuprofen prescribed at a TDS frequency. There were 6% of cases presenting with bleeding, none returned to theatre. Coblation was used in about 40% of cases (extracapsular and intracapsular). For the second prospective cycle, 55% of patients have been prescribed the correct ibuprofen dosage of 7.5mg/kg QDS, with reduced opioid prescribing. No patients were re-admitted with post-operative pain and only a low number of patients presented with post-tonsillectomy bleeds. Conclusions Changing the dosing of ibuprofen to 7.5mg/kg QDS and ensuring departmental consistency has resulted in adequate analgesia dosing with no admissions for poorly controlled pain post-tonsillectomy. We feel a secondary impact is on reduced bleeding rates.

Role of Bupivacaine Infiltration into Tonsillar Fossa in Post-tonsillectomy Analgesia

Role of Bupivacaine Infiltration into Tonsillar Fossa in Post-tonsillectomy Analgesia

Role of Pre-incisional Bupivacaine Infiltration in Post-tonsillectomy Analgesia.

Tonsillectomy is one of the common surgeries performed by Otorhinolaryngologists and is associated with several morbidities with pain being the commonest, which can cause considerable delay in oral intake and discharge from the hospital. As a commonly performed day care procedure nowadays, pain control is much better than what it used to be previously observed. Therefore newer drugs are being constantly studied inorder to give better analgesia and post operative comfort to the patient with minimal side effects. The main obstacle being finding the best medical method to control pain with minimum side effects, but at the same time making sure that the patient is adequately hydrated and they resume regular eating as soon as possible. Our aim is to study the role of pre-incisional 0.5% bupivacaine versus normal saline infiltration in post-tonsillectomy analgesia. Over a period of 1year, 30 patients with each group of 15 were compared for the efficacy of 0.5% bupivacaine and 0.9% normal saline in post-operative tonsillectomy pain management. After thorough clinical examination and investigations, all patients underwent tonsillectomy by dissection and snare method. After intubation, 0.5% bupivacaine or normal saline was infiltrated in the tonsillar fossa and pain scores was obtained using Visual Analogue Scale (V.A.S) at 6, 12 and 24h post operatively. Using Mann-Whitney non-parametric statistical test, inter-group analysis was done which showed highly significant p-value (<0.0001) indicating that the pre-incisional bupivacaine infiltration is highly effective in reducing the post-tonsillectomy pain. Hence, we recommend the routine use of pre-incisional peritonsillar infiltration of 0.5% bupivacaine in all tonsillectomy/adenotonsillectomy cases, irrespective of the age of the patient to reduce the post tonsillectomy pain and other discomfort associated with it.

Recent advances in post-tonsillectomy analgesia

Recent advances in post-tonsillectomy analgesia

How Safe Is it to Use Nonsteroid Anti-inflammatory Drugs for Post-tonsillectomy Analgesia in Children? Implications for Clinical ENT Practice.

How Safe Is it to Use Nonsteroid Anti-inflammatory Drugs for Post-tonsillectomy Analgesia in Children? Implications for Clinical ENT Practice.

Comparative study between pre-emptive transcutaneous versus transoral ultrasound-guided peritonsillar space infiltration with bupivacaine during elective tonsillectomy

Background Ultrasound (US) as a technique is safe, readily available, quick, and portable allowing more accuracy of different regional blocks and local infiltration. It allows imaging of the mouth, oropharynx, infrahyoid structures, larynx, vocal cords, and the trachea. Recently, point-of-care US has been shown to improve accuracy in US-guided block with local anesthetic infiltration. Objective The objective of the study was to compare the effect of pre-emptive transoral US-guided peritonsillar infiltration versus transcutaneous US-guided peritonsillar infiltration with bupivacaine for post-tonsillectomy analgesia on surgical field, and surgeon satisfaction (intraoperative reactionary bleeding). Study design A clinical, prospective study. Patients and methods Sixty patients (25 men, 35 women) were admitted for tonsillectomy at the ENT Department of the Al-Azhar and Ain Shams University Hospitals. The age of the patients ranged from 3 to 15 years. The patients were divided into cutaneous group consisting of 30 patients who were submitted to transcutaneous US-guided peritonsillar infiltration with bupivacaine and the oral group consisting of 30 patients who were submitted to transoral US-guided peritonsillar infiltration with bupivacaine. Results The study showed no statistically significant difference between the two studied groups regarding age, sex, and weight with P values of 0.602, 0.190, and 0.164, respectively. The oral group was significantly shorter as regards the time needed to detect peritonsillar space and the time needed to perform peritonsillar infiltration with a P value of 0.000. The cutaneous group gave significantly better results as regards direct surgeon satisfaction questionnaire about bleeding and surgical field, weighing amount of soaked gauze with blood per tonsil, dissection time, and the amount of blood suctioned with P value 0.118, 0.318, 0.851, and 0.112, respectively. Conclusion Peritonsillar space can be infiltrated equally and safely using transcutaneous US or transoral US and may be considered as an alternative technique to traditional blind technique when performed by an experienced team.

Efficacy of pre-incisional peritonsillar infiltration of ketamine for post-tonsillectomy analgesia in children.

To assess the efficacy of pre-incisional peritonsillar infiltration of two doses of ketamine on postoperative analgesia compared with peritonsillar normal saline in children undergoing tonsillectomy. Double blind, randomized controlled trial. Department of Anaesthesiology, Surgical Intensive Care and Pain Management, Civil Hospital, Karachi, Dow University of Health Sciences, from August 2008 to January 2009. Seventy-five ASA physical status one patients, aged 5 - 12 years scheduled for tonsillectomy were enrolled in this study. Patients were divided into three groups of 25 each. Group-A received normal saline, Group-B, ketamine 0.5 mg/kg while group-C ketamine 1 mg/kg respectively. All medications were 2 ml and were applied 1 ml per tonsil; 3 minutes before tonsillectomy incision. Anaesthesia was induced and maintained with standard technique. All patients were monitored throughout surgery. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale were used to evaluate pain levels and sedation respectively after operation. Mean duration of analgesia was significantly higher in group-C (17.28 ± 5.33 hours) as compared to group-B (11.36 ± 4.15 hours) and A (3.2 ± 0.71 hours) as well as group-B was also significantly higher than group-A (p < 0.05). Group-A had significantly higher pain scores than group-B and group-C. Both B and C groups had comparable pain scores, which were statistically significant at 6 and 8 hours. Single 0.5 or 1 mg/kg injection of ketamine given before surgical incision by peritonsillar infiltration provides efficient pain relief during postoperative period without significant side-effects in children undergoing tonsillectomy.

Adult post-tonsillectomy analgesia and rates of readmission

Adult post-tonsillectomy analgesia and rates of readmission

AB082. 225. A comparative audit of post-tonsillectomy pain management

Background: Post-operative pain is common and a relatively common reason for post-operative patients attending Emergency Department (ED) and hospital readmission. Inadequate pain relief is an ongoing problem particularly in adults after tonsillectomy. It is associated with poor feeding, dehydration, delayed healing and increased risk of haemorrhage. Despite many publications comparing postoperative pain management, there is a lack of standardised post tonsillectomy analgesia prescription. This has to lead to an individual based prescription contrary to evidence-based prescription. The aim of the current study was to compare the readmission rate for pain in adult post tonsillectomy patients between a combination of diclofenac and paracetamol at discharge as against a cocktail of paracetamol, Arcoxia and Oxynorm.

The Use of Ibuprofen in Posttonsillectomy Analgesia and Its Effect on Posttonsillectomy Hemorrhage Rate

To determine the effect of ibuprofen on posttonsillectomy bleeding when compared with codeine in posttonsillectomy analgesia. Case series with chart review. Tertiary care children's hospital, Philadelphia, Pennsylvania. On July 1, 2012, our institution transitioned from acetaminophen with codeine to ibuprofen for posttonsillectomy analgesia. Pediatric patients (0-18 years old) who underwent surgery from July 1, 2010, to June 30, 2012, were placed in the codeine cohort, and those who underwent surgery from July 1, 2012, to June 30, 2014, were placed in the ibuprofen cohort. A total of 6014 patients underwent tonsillectomy between July 1, 2010, and June 30, 2014, and 211 patients presented for posttonsillectomy hemorrhage during the same period. The incidence of readmission for posttonsillectomy hemorrhage was 3.4% and 3.6% (P = .63; odds ratio [OR] = 1.07; 95% confidence interval [95% CI]: 0.811-1.410) for the codeine and ibuprofen groups, respectively, and the incidence of second operation for control of posttonsillectomy bleeding for the codeine and ibuprofen groups was 1.9% and 2.2% (P = .54; OR = 1.117; 95% CI: 0.781-1.600), respectively. Patients aged 11 to 18 years demonstrated a higher incidence of posttonsillectomy bleeding events overall. When age is controlled, multivariate logistic regression demonstrated no statistically significant increase in posttonsillectomy bleeding events among pediatric patients treated with ibuprofen versus patients treated with codeine (readmission: P = .617; OR = 0.932; 95% CI: 0.707-1.228; reoperation: P = .513; OR = 0.887; 95% CI: 0.618-1.272). Age is an independent risk factor for posttonsillectomy bleeding. When age is controlled, there is no statistically significant increase in the incidence of posttonsillectomy bleeding events among patients treated with ibuprofen when compared to patients treated with codeine.

Post-tonsillectomy pain control: consensus or controversy?

Pediatric post-tonsillectomy analgesia continues to be highly debated and an area of active research. Tonsillectomy pain can leadto significant patient morbidity, and incur potentially avoidable healthcare costs. Moreover, the various analgesic classes, each present their own risk profiles and unique side effects when used in children post-tonsillectomy. This review delineates the clinical and pathophysiological basis for post-tonsillectomy pain, types of analgesics and their risk profiles, as well as special considerations in this clinical population and a review of alternative analgesic treatment options. This article presents a summary of recent literature and discusses evidence-based management options to aid medical and allied health professionals who may encounter these patients.

Pain after surgery in children: clinical recommendations.

This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations. Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions. Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.

The analgesic efficacy of preincisional peritonsillar versus intravenous ketamine with bupivacaine infiltration for tonsillectomy in children: a randomized double-blind controlled study

Objective This study aimed to evaluate the postoperative analgesic efficacy of either preincisional peritonsillar infiltration of ketamine in combination with bupivacaine, or intravenous ketamine combined with infiltration of bupivacaine. Patients and methods A total of 60 patients were randomized into three groups: intravenous group, in which patients received intravenous ketamine (0.5 mg/kg) in 10 ml plus peritonsillar infiltration of bupivacaine 2 ml (5 mg/ml); infiltration group, in which patients received peritonsillar infiltration of ketamine (0.5 mg/kg) in 2 ml plus bupivacaine 2 ml and intravenous 10 ml saline; and placebo group, in which patients received 10 ml intravenous saline and peritonsillar infiltration of 2 ml saline plus 2 ml bupivacaine 2 ml/tonsil. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson scale were used to evaluate pain and sedation, respectively. Time to first analgesic request and total analgesic request, total analgesic consumption during 24 h postoperatively, intraoperative blood loss, and adverse effects were evaluated. Results Time to analgesic request was significantly prolonged in the intravenous and infiltration groups (4.3 ± 2.1 and 11.6 ± 3.6 h, respectively) compared with the placebo group (1.2 ± 1.2 h), with significant prolonged time in the infiltration group compared with the intravenous group. Significant lower (CHEOPS) scores and significant lower analgesic consumption were observed in the intravenous and infiltration groups (69 ± 4.1 and 45.1 ± 2.1 mg), respectively, compared with the placebo group (90.6 ± 5.3 mg). Both the intravenous and infiltration groups had comparable pain scores, with statistical significance at 4, 6, and 8 h postoperatively. Dysphagia was significantly higher in the placebo group compared with the intravenous and infiltration groups. No serious complication was reported in the three groups. Conclusion Intravenous or peritonsillar infiltration of ketamine with bupivacaine enhanced post-tonsillectomy analgesia in children. In comparison, the analgesic efficacy of infiltration of ketamine was superior to intravenous administration, without significant side effects.

Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. ObjectiveIn this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. Method120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/ or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. ResultsNo significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. ConclusionIntravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

Lidocaïne en aérosol après l’amygdalectomie chez 1’enfant

Post-tonsillectomy analgesia was compared using ten per cent aerosol lidocaine or 1.5 mg.kg-1 intramuscular codeine. Thirty ASA physical status I or II children between two and ten years of age were assigned, in a random fashion, to one of two groups: Group A received codeine 1.5 mg.kg-1 intramuscularly, Group B received a total dose of 4 mg.kg-1 of ten per cent aerosol lidocaine on the tonsillar beds. For both groups, the treatment was administered at the end of the surgical procedure. The postoperative comfort state was assessed on a global scale using the following statement: (1) comfortable = 1, (2) agitation = 2, (3) uncontrollable = 3. Assessment of postoperative comfort was recorded after 20 min in the post-anaesthetic recovery room. Blood samples for lidocaine concentration estimation were obtained at 5, 7.5, 10, and 15 min after administration. Finally, the time of recovery was recorded. The immediate post-anaesthetic comfort observed with ten per cent aerosol lidocaine was statistically superior to that obtained with 1.5 mg.kg-1 intramuscular codeine. The maximal systemic lidocaine concentration which was 2.1 +/- 0.2 micrograms.ml-1 was well below the accepted toxic level of 5.3 micrograms.ml-1. The recovery room times were not statistically different between the two groups. In conclusion, 4 mg.kg-1 of ten per cent aerosol lidocaine applied directly on the tonsillar beds was shown a superior immediate post-tonsillectomy analgesic technique.

Syrup formulations for post-tonsillectomy analgesia:

SummaryPost-tonsillectomy analgesia from ibuprofen, aspirin and placebo is compared in a double-blind study. The results are reported showing ibuprofen to have greater therapeutic benefit than placebo whereas aspirin did not. Methods of providing pain relief after tonsillectomy and the relative clinical merits of ibuprofen and aspirin are discussed.