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PubMed2003

Ketoprofen for postoperative pain after uvulopalatopharyngoplasty and tonsillectomy: two-week follow-up study.

OBJECTIVE: In our previous study, we reported that both uvulopalatopharyngoplasty (UPPP) and tonsillectomy are associated with unacceptable intense pain during the first 24 hours after surgery. To investigate the pain progression at home, we followed the same 53 patients for 14 days after surgery. Twenty-two patients underwent tonsillectomy and 31 patients underwent UPPP. STUDY DESIGN: A prospective, longitudinal, parallel-group study was conducted. METHODS: Beginning on the first postoperative day, the patients were allowed to use 50 mg ketoprofen capsules at a dosage of 5 mg/kg/24 hr. The patients evaluated their own pain four times a day for the first 5 days. Two weeks after the surgery during a follow-up visit patients reported the present pain; and a total consumption of analgesics, and all adverse events for 14 days. RESULTS: Patients in both study groups had significant pain, especially in the morning, for the first week after surgery. In half of the patients, severe pain interfered with eating and sleeping, and in one third of the patients, the pain lasted 2 weeks or longer. The need for ketoprofen was significantly higher after UPPP than that after tonsillectomy (P = 0.001). One patient after tonsillectomy and 3 patients after UPPP needed electrocautery to stop secondary bleeding. CONCLUSIONS: Both UPPP and tonsillectomy are associated with intense postoperative pain. Standard ketoprofen capsules are too short-acting to ensure undisturbed sleep.

Adult↗

PubMed1997

Microscopic tonsillectomy: a double-blind randomized trial.

OBJECTIVE: To evaluate microsurgical bipolar cautery tonsillectomy (TEmic) by comparing it with traditional blunt dissection tonsillectomy (TEtrad). DESIGN: A double-blind prospective randomized trial with stratification in two age groups. PATIENTS: 200 consecutive patients undergoing tonsillectomy for tonsillar hypertrophy, or recurrent or chronic tonsillitis. OUTCOME MEASURES: Duration of surgery, intraoperative bleeding, daily postoperative pain and otalgia, postoperative bleeding episodes. METHODS: Duration of surgery and operative bleeding were evaluated by the anesthesiologist. The patients were instructed to record daily pain and otalgia. Final postoperative evaluation was done by a different physician, blinded to the surgical technique. RESULTS: Mean intraoperative bleeding was 12 ml for TEmic and 36 ml for TEtrad (P < 0.001). Mean duration of surgery was 37 minutes for TEmic and 36 minutes for TEtrad (NS). Otalgia was present in 41% of TEmic patients and 69% of TEtrad patients (p < 0.001). Daily postoperative pain was lower in the TEmic group than it was in the TEtrad group for the entire study period (10 days). Postoperative hemorrhage was present in three TEmic patients (3%) and in eight TEtrad patients (8%), a difference that did not reach significance (p > 0.1). CONCLUSION: Microsurgical bipolar cautery tonsillectomy compares favorably with traditional techniques in terms of intraoperative bleeding, postoperative pain, otalgia, and hemorrhage. This technique combines the hemostatic advantage of cautery dissection, the excellent visualization achieved by a microscope, and, with the use of a video, greatly improves the physician's ability to teach how to perform a tonsillectomy.

Biological Products↗

PubMed2002

Excessive post-tonsillectomy hemorrhage requiring ligature of the external carotid artery.

UNLABELLED: Ligature of the external carotid artery (LECA) is the method of choice in patients with excessive post-tonsillectomy hemorrhage. This retrospective study was undertaken to evaluate the incidence, characteristics and warning signs of excessive post-tonsillectomy hemorrhage. BASIC PROCEDURES: Between January 1988 and December 2000, a total of 25 patients had to be treated by LECA. Tonsillectomy had been previously performed in seven patients at our department (group A) and in 18 patients elsewhere (group B). MAIN FINDINGS: LECA was performed in most cases 6 (group A) and 11 days (group B) after tonsillectomy. There was one case with lethal outcome. A total of 12 patients (group B) had been operated by two surgeons. PRINCIPAL CONCLUSIONS: Excessive bleeding following tonsillectomy may occur as delayed bleeding, abrupt and require immediate LECA and blood transfusion. Prior recurrent episodes of bleeding can be a warning sign. Anatomical vascular abnormalities have to be considered. Inpatient policy in these underestimated cases was life-saving.

Adolescent↗

PubMed2003

Post tonsillectomy morbidity: following the introduction of single-use-instruments.

OBJECTIVE: Following the introduction of single-use-instruments (SUI) for tonsillectomy in January 2001 in UK, the Medical Devices Agency (MDA) received reports of significant increase in secondary haemorrhage in some centres. This was believed to be related to electrosurgical (diathermy) forceps. The aim of this study is to compare post tonsillectomy morbidity before (year 2000) and after (year 2001) the introduction of SUI in a unit where bipolar dissection is the most popular method of dissection. METHOD: The case notes of all tonsillectomy patients between 20 April and 31 October for the years 2000 (145 patients) and 2001 (166 patients) were reviewed. The patients' age and sex, other concurrent operations, grade of surgeon, dissection and haemostasis methods, length of post operative hospital stay and the reason for prolonged stay (if more than one night) were noted. Readmitted cases were analysed to identify the cause and the management. RESULTS: There was no case of reactionary haemorrhage in both the non SUI (year 2000) and the SUI (year 2001) groups. For the non SUI versus SUI group, 6.2 versus 4.8% stayed more than one night post operatively; 4.8 versus 5.4% were readmitted for secondary haemorrhage with 1.4 versus 2.4% return to theatre to control bleeding, respectively. The average hospital stay for the readmitted cases were 2.1 versus 1.6 days and the average time lapse between tonsillectomy and secondary haemorrhage were 6.7 versus 6 days respectively. CONCLUSION: There was no significant difference in post tonsillectomy morbidity following the introduction of SUI.

Adolescent↗

PubMed2003

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

OBJECTIVE: Most studies investigating the effect of preincisional injection of local anaesthetic with adrenaline in tonsillectomy have used rather large doses and an inter-individual study design. They are inconclusive regarding the effect on post-tonsillectomy pain but have shown that the peroperative blood loss is reduced. However, side effects to high adrenaline doses are common. In the present study, the effect of injecting a small dose of lidocaine-adrenaline was investigated by using an intra-individual study design. METHODS: In this randomised double-blind study 52 patients (33 women and 19 men) received unilateral preincisional injection of 3-ml lidocaine-adrenaline before tonsillectomy. RESULTS: the difference in blood loss was highly significant with a more than 50% reduction in peroperative blood loss in the infiltrated side. Time to achieve haemostasis for one tonsil side was reduced from 6.0 to 4.0 min. No side effects were observed. At the operation day (mean 4.9 h after operation), the visual analogue scale for pain at the side infiltrated with local anaesthetics was 2.78 compared to 4.00 in the control side (P=0.05). CONCLUSION: Low-dose injection of lidocaine-adrenaline before tonsillectomy reduces blood loss and has a small but significant beneficial effect on early postoperative pain. Furthermore our results indicate that operation time is reduced. We therefore recommend subcapsular injection of 3 ml of 1% lidocaine with 1/200.000 adrenaline under each tonsil before tonsillectomy.

Anesthetics, Local↗

PubMed1999

Immediate tonsillectomy for peritonsillar abscess.

OBJECTIVE: Peritonsillar abscess (PTA) is one of the most common infectious diseases of the head and neck region requiring surgical intervention to relieve symptoms such as severe throat pain, fever, dysphagia, and trismus. However, the appropriate management of PTA is still controversial. In Europe and the US, immediate tonsillectomy under general anesthesia has been accepted as the treatment for PTA. But in Japan, immediate tonsillectomy has been regarded as contraindicated for PTA because of difficulties encountered in the operation during the acute stage, as well as possible postoperative complications. METHODS: A total of 103 cases of PTA treated at our clinic during the past 16 years were reviewed; immediate tonsillectomies had been performed in 99 of them. Surgical findings, postoperative course, and bacteriological examination were surveyed. RESULTS: The results showed that immediate tonsillectomy under general anesthesia was carried out safely without complications. Dramatic relief of the symptoms was obtained within a few days following each operation. A high incidence of anaerobes was observed by bacteriological examination, suggesting that sufficient drainage is required to treat this disease. CONCLUSION: We conclude that immediate tonsillectomy should be performed for peritonsillar abscess.

Acute Disease↗

PubMed2002

[Postoperative comfort in pediatric outpatient tonsillectomy].

OBJECTIVE: Evaluate the comfort in children after ambulatory tonsillectomy, disregarding the surgical technique and with a systematic prescription of paracetamol and codeine. The study lasted 4 days including the day of surgery. STUDY DESIGN: [corrected] Prospective study during 5 months. PATIENTS AND METHODS: We performed a prospective study over a five-month period to evaluate the comfort in children after ambulatory tonsillectomy. Opioids were used for analgesia during surgery, morphine and propacetamol in the recovery room, and a systematic prescription of paracetamol-codeine between Day 0 to Day 3 at home. The assessment of pain was made by nurses and the family, considering 6 endpoints: spontaneous pain and when swallowing by verbal scale (0 to 4), occurrence of PONV (0 or 1), quality of sleep (0 or 1), quality of feeding (0 or 1) and play (0 or 1), combined in a global score of 0 to 12, with a score < or = 4 very satisfactory. RESULTS: 78 children were included, 49 tonsillectomy by dissection, 29 by Sluder. The score were < or = 4 at Day 0 and Day 1 in 53 children, but statistical analysis (univariate analysis) showed difference between the two surgical procedures with a global comfort score better and PONV lower with dissection procedure. CONCLUSION: The use of paracetamol-codeine after tonsillectomy offers a reliable analgesia with very satisfactory scores of comfort. Such prescription is effective in ambulatory tonsillectomy if a rigorous selection of patients is made.

Acetaminophen↗

PubMed1991

Iatrogenic influences on the heritability of childhood tonsillectomy: cohort differences in twin concordance.

In 1980-82, a mailed questionnaire was completed by 3,810 pairs of adult twins enrolled on the Australian NH&MRC Twin Register. Twins were asked whether they had had their tonsils out and, if so, at what age. The sample was divided into four birth cohorts of approximately equal size, and only childhood tonsillectomy (to the age of 18) was considered. The prevalence of tonsillectomy differed markedly between cohorts, being highest in those born in the 1940s and early 1950s. Within each cohort, the prevalence was very similar in MZ and DZ twins, yet concordance was much higher in MZ twins, indicating the importance of genetic factors in predisposition to tonsillectomy. However, the proportions of variance in liability due to genetic and shared environmental factors differed markedly between cohorts. In the 1950s, when tonsillectomy was fashionable, shared environment accounted for 60% of variance and genetic factors for only 29%. However, by the early 1960s, when tonsillectomy was going out of fashion, heritability was up to 0.82 and shared environment accounted for only 10% of variance. Our results illustrate, once again, that heritability is not a constant, but depends on the precise characteristics of the population and the time at which it is studied.

Australia↗

PubMed1988

Post-tonsillectomy analgesia: the use of benzocaine lozenges.

Tonsillectomy frequently results in a significant degree of post-operative pain. Conventional management consists of the administration of intra-muscular opiates prior to the commencement of oral analgesia and is often inadequate, producing variable levels of pain relief. One of the recommended uses of benzocaine lozenges is the relief of throat discomfort following tonsillectomy, but there are no clinical trials to support this claim. Therefore, a prospective placebo controlled trial was undertaken to compare the efficacy of benzocaine lozenges (10 mg.) with standard oral analgesia in the management of post-operative pain following tonsillectomy in an adult population. Consecutive patients undergoing elective tonsillectomy were randomised to receive either benzocaine lozenges (10 mg.) or placebo. Intake of supplementary oral analgesia was recorded, and the level of post-operative pain was assessed by use of a visual linear analogue scale. There was no significant difference in analgesic intake or pain severity as measured by linear analogue between the two groups. These results suggest that there is no benefit in administering benzocaine lozenges for the relief of post-tonsillectomy pain, and its use in this situation cannot be recommended.

Adolescent↗

PubMed1991

Combined study to assess the role of calcium alginate swabs and ligation of the inferior tonsillar pole in the control of intra-operative blood loss during tonsillectomy.

Bleeding is the major source of morbidity and mortality of tonsillectomy and most operative time is spent securing haemostasis. Calcium alginate reduces experimental wound blood loss. This study assessed the efficacy of alginate swabs during tonsillectomy and inferior tonsillar pole ligation in the control of blood loss during tonsillectomy. Ninety-nine tonsillectomy patients were randomized to gauze or alginate swab use. A haemoglobinometer measured blood losses collected by suction during dissection and by swab until haemostasis was secured. Operative time, complications and healing were also assessed. Mean total blood losses and operative times were similar for the two groups. Swab blood loss was significantly lower for surgeons who ligated the lower tonsillar pole, compared with surgeons who used a snare. This finding was independent of swab type. Independent assessment showed no difference in the healing rate. Alginate swabs offer no advantage over gauze in terms of blood loss, operative time or complications of tonsillectomy. The results show that routine lower pole ligation significantly reduces post-dissection blood loss. We suggest that this technique should be more widely adopted.

Adolescent↗

PubMed1991

Peritonsillar abscess: risk of disease in the remaining tonsil after unilateral tonsillectomy à chaud.

The occurrence of disease in the remaining tonsil after unilateral tonsillectomy à chaud in the treatment of peritonsillar abscess, was studied in 536 patients. No patient had a history of previous severe tonsillitis at the time of the unilateral tonsillectomy, 6.1 per cent of the patients were readmitted for surgery of the remaining tonsil during the follow-up period. Ninety-seven per cent of these patients were younger than 30 years of age. Previous investigations have shown increasing frequency by age of pharyngitis after bilateral tonsillectomy. We suggest bilateral tonsillectomy in all cases of patients younger than 30 years old who suffer from peritonsillar abscess irrespective of previous tonsillar disease. Patients older than 30 should be treated with unilateral ablation, unless there is a clear indication for bilateral tonsillectomy.

Adolescent↗

PubMed1992

Acute tonsillectomy in the management of infectious mononucleosis.

Life-threatening upper airway obstruction can be caused by tonsillopharyngitis secondary to infectious mononucleosis (IM). The administration of corticosteroids, emergency tracheostomy and acute tonsillectomy have been advocated as ways of managing this problem. In a series of 25 patients admitted over a five-year period with IM, 15 were judged to have symptoms severe enough to warrant the administration of corticosteroids. Six of these 15 patients had little improvement in their condition and thus underwent acute tonsillectomy. There were no significant complications of this surgery. A further three patients who received corticosteroids required tonsillectomy for recurrent tonsillitis later in the study period. By contrast, only one of the ten patients who did not receive corticosteroids subsequently required tonsillectomy. Acute tonsillectomy is of value in selected cases of IM tonsillopharyngitis. It may decrease the morbidity of recurrent tonsillitis after IM, in addition to averting the immediate risk of respiratory obstruction.

Acute Disease↗

PubMed2006

Post-tonsillectomy haemorrhage: a prospective, randomized, controlled clinical trial of cold dissection versus bipolar diathermy dissection.

OBJECTIVE: To determine whether bipolar dissection tonsillectomy is associated with a higher post-operative haemorrhage rate than cold dissection tonsillectomy. DESIGN: Prospective, randomized, controlled trial. SETTING: Otolaryngology department of a teaching hospital. PARTICIPANTS: Two hundred and forty-five patients undergoing elective tonsillectomy between July 2002 and November 2004. INTERVENTIONS: Patients were randomly assigned to either bipolar dissection or cold dissection (with bipolar haemostasis). MAIN OUTCOME MEASURES: Post-operative haemorrhage rates, management (conservative or surgical) and blood transfusion requirements were recorded. The grade of surgeon and history of quinsy were also recorded. RESULTS: One hundred and forty-one patients (58 per cent) were randomized to the bipolar dissection and 104 (42 per cent) to the cold dissection groups. Seventeen patients (12.1 per cent) in the bipolar dissection group and eight patients (7.7 per cent) in the cold dissection group suffered haemorrhage (p = 1.0; degrees of freedom (Df) 0.0; 95 per cent confidence intervals (CI) -0.1 to 0.0). The haemorrhage rates for procedures conducted by senior house officers, specialist registrars and consultants were 11.4 per cent, 10.3 per cent and 5.0 per cent, respectively. Two patients required surgical intervention, both from the bipolar dissection group. No patients required blood transfusion. A history of quinsy was not associated with an increased haemorrhage rate. CONCLUSION: The difference in haemorrhage rates between groups and surgeon grades did not reach statistical significance. Nonetheless the trend towards a greater incidence of haemorrhage in the bipolar group and in procedures conducted by more junior surgeons during the trial raised concerns. The results of the National Prospective Tonsillectomy Audit and our interim results have led us to abandon the trial and disallow the use of bipolar dissection in tonsillectomies performed by junior staff members.

Adult↗

PubMed1998

Bacteraemia during tonsillectomy: a study of the factors involved and clinical implications.

Post-tonsillectomy bacteremia is a well-recognized aetiological factor in streptococcal endocarditis, and prophylactic penicillin has been recommended to reduce its incidence in susceptible patients undergoing tonsillectomy. Recent studies have shown a change in the microflora and an increase in the number of penicillin-resistant organisms in the tonsils of patients undergoing tonsillectomy. The aim of this study was to assess the incidence of post-tonsillectomy bacteraemia, to identify the micro-organisms associated with it and to review the suitability of penicillin in prophylactic regimens. The relationship between positive blood cultures and several clinical parameters such as fever, vomiting, pharyngeal discomfort, or dysphagia was also analysed. Of the 102 patients included in the study, 41 (40.1%) had positive post-tonsillectomy blood cultures. Haemophilus influenzae were isolated from 23 (56%) of the positive cultures and Streptococcus viridans in 15 (36.5%). Twenty-five per cent of H. influenzae produced beta-lactamase and only 30% of streptococci of the viridans group were penicillin-sensitive. Positivity of the blood cultures was not related to fever, discomfort, surgical technique, type of tonsil, or any of the parameters studied. Bacteraemia seems to be related to traction of the tonsil before dissection rather than direct spread of bacteria into the opened vessels. Using a beta-lactamase stable antibiotic instead of penicillin for prophylaxis would be more appropriate.

Anti-Bacterial Agents↗

PubMed1998

The relation between tonsillectomy and snoring.

The aim of this study was to determine the relation between snoring and tonsillectomy. The grossly enlarged tonsils of a heavily snoring child or adult with upper airway obstruction is usually sufficient indication for tonsillectomy. The authors wondered if tonsillectomy could affect snoring, no matter what the age and the indication for surgery. One thousand people took part in this study: a random sample of patients aged between 2 and 89 years of age, and those accompanying them in the ENT outpatients. The prevalence of snoring was 12.5-48%, mainly in men. The degree of snoring was graded from non-snorers to mild, moderate and severe snorers. In 19.8% of the sample tonsillectomy had already been performed, usually in childhood. The authors conclude that tonsillectomy does not reduce the likelihood of becoming a snorer.

Adolescent↗

PubMed1999

Day case paediatric tonsillectomy: a review of three years experience in a dedicated day case unit.

Tonsillectomy is one of the most common surgical procedures performed in children. Day case tonsillectomy is common in many parts of the USA but remains controversial in the UK. Day case tonsillectomy in children has been performed in a dedicated paediatric day care unit at the May day Hospital since 1994. The results for the years 1995-1997 were reviewed. In these years 928 true day case tonsillectomies were performed. Reactionary haemorrhage occurred in 0.97% (nine children) but only three children required a return to theatre. All bleeding occurred within the standard observation period. There were no deaths. The overall effective day case rate was 95.7%, only 31 children needing unplanned admission, mainly for postoperative vomiting. The results suggest that day case tonsillectomy can be safely and successfully performed, with a dedicated paediatric day case unit and a favourable population geography.

Adolescent↗

PubMed1999

A study of postoperative fever following paediatric tonsillectomy.

The aetiology of post-tonsillectomy fever is obscure. Bacteraemia during surgery, anaesthetic agents and the inflammatory response of tissue to injury have been implicated. A prospective study was undertaken in 100 consecutive children to evaluate the occurrence and severity of fever in the 24 h after tonsillectomy and its relationship to bacteraemia during surgery and qualitative and quantitative cultures (colony counts) of organisms in tonsil core tissue. Fifty-four patients had a fever (> 37.5 degrees C) postoperatively, of whom, 30 had a fever greater than 38 degrees C. Blood cultures during tonsillectomy were positive in 22 patients. There was no statistically significant difference between the occurrence of fever and the techniques of tonsillectomy and haemostasis. There was also no association between positive blood, core or surface cultures and the incidence or severity of fever nor any association between colony count in core cultures and fever. Our results suggest that postoperative fever in the 24 h following tonsillectomy is not caused by infection.

Adolescent↗

PubMed2001

Is the incidence of tonsillectomy influenced by the family medical or social history?

Previous reports have suggested that the incidence of tonsillectomy, and/or tonsillitis in children, is influenced by factors such as parental smoking, maternal health and previous parental tonsillectomy. The reports have considered single factors and have not considered the possible confounding effect of the factors upon one another. Previous studies have not investigated the influence of social class. This paper uses the background of a large case-control trial of children awaiting tonsillectomy for recurrent tonsillitis, and a normal control group to study the influence of parental smoking, parental surgical history, parental tonsillectomy, family atopy and social class upon the reported incidence of sore throats and tonsillitis. A multivariate analysis is used. The paper shows that parental smoking, previous parental surgery and social class have no effect upon the number of sore throat episodes. A history of parental tonsillectomy and a family history of atopy are both significant predictive factors for the number of reported sore throats and episodes of tonsillitis in children.

Case-Control Studies↗