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PubMed1994

Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy.

BACKGROUND: Children undergoing tonsillectomy are at high risk for postoperative vomiting. This study was undertaken to compare ondansetron with metoclopramide and droperidol for the prevention of postoperative vomiting after tonsillectomy. METHODS: Two hundred fifty-six pediatric patients, ages 2-12 years, scheduled for outpatient tonsillectomy were enrolled in a prospectively randomized, double-blinded investigation and assigned to one of four treatment regimens: placebo (saline), ondansetron 0.15 mg.kg-1, metoclopramide 0.5 mg.kg-1, or droperidol 0.075 mg.kg-1. Study drugs were administered intravenously after inhalation induction of anesthesia with halothane, nitrous oxide, and oxygen. No premedication or neuromuscular blocking agents were used. Tracheal extubation was performed while patients were still deeply anesthetized. Acetaminophen and meperidine were given for postoperative pain. Patients were observed in the recovery room for a minimum of 4 h before discharge. Parents were contacted by telephone 24 h later for follow-up. RESULTS: Ondansetron reduced the incidence of postoperative emesis from 62% to 27% (relative risk 0.45, 95% confidence interval 0.29 to 0.70, P < 0.001). Metoclopramide and droperidol had no significant effect on postoperative vomiting. CONCLUSIONS: The intravenous administration of ondansetron 0.15 mg.kg-1 is highly effective in reducing postoperative emesis in children undergoing tonsillectomy. Metoclopramide and droperidol at the doses tested are ineffective in this population.

Acetaminophen↗

PubMed1981

Tonsillectomy in Maine: regulation versus education as modulators of medical care.

The reduction in the rate of tonsillectomy, using the state of Maine as an example, and the causes thereof are addressed. Are federal and state regulations required to change the behavior of physicians and the public, or is education of greater importance? A study of tonsillectomy in the state of Maine was based on data covering a period of approximately 30 years. The data were based on direct contact with hospitals, in which we achieved the cooperation of virtually all of the hospitals of Maine, encompassing 98% of the hospital beds. These data were placed in context by information provided by the Maine Health Data Service, and by information for the northeastern United States, for the eastern United States, and for the entire United States, from the Department of Health, Education and Welfare. The operation of tonsillectomy and its variants, including adenoidectomy, has declined remarkably in the past 30 years, most drastically in the past eight years. It now occupies only 4.5% of the total operative admissions for the State, where it formerly was 17%. It now has a populational incidence for the State of 3.3 operations per thousand population per year, whereas it formerly was at a level of about 10.0. From this study, as well as from physicians in Maine, to whom an informal questionnaire was sent, it is clear that this reduction has come about largely because of education of physicians and the public. Increased awareness by the public, pediatricians and general practitioners of the limitations of this operation has been significant. In addition, there is a general sense of improved general health of young people in Maine, with fewer chronic respiratory infections. Some negative opinions were expressed, including the possibility that peritonsillar abcesses may be more frequent in the future and that some pediatricians and general practitioners overuse antibiotics. Federal regulations, state regulations, Medicare, Medicaid, Blue Cross or Blue Shield regulations concerning tonsillectomy were not instituted at any point in the State of Maine, during the period under study. There were no alterations in payment, second opinion programs or other restrictions or constraints placed on the operation at any level of official or hospital regulation. Formerly performed in large numbers by general practitioners, family practitioners, and general surgeons, the operation(s) is now predominantly carried out by trained otolaryngologists, largely board certified. Evidence is presented to support the view that concentration of this operation in the hands of fewer, more highly trained surgical specialists has been positively associated with its sharper indications and declining frequency. The conclusion is offered that increased education of physicians, both specialists and general practitioners as well as family doctors, and of the public as a whole, is the most important single factor in producing this significant alteration in the behavior of the health care system in the State of Maine. Effective limitation of the operation to specialists has been an important feature both of this educational process and of the more rational use of the operation(s).

Adenoidectomy↗

PubMed1999

A prospective randomized double-blind trial of fibrin glue for pain and bleeding after tonsillectomy.

OBJECTIVES: The notable morbidity of tonsillectomy includes considerable postoperative pain and a rate of postoperative bleeding that have remained largely uninfluenced by modern surgical techniques or medication. Fibrin glue is known to have a hemostatic effect in some settings, and there is research suggesting it may also reduce postoperative pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy. STUDY DESIGN: A prospective randomized double-blind study was performed on 50 consecutive adult patients undergoing tonsillectomy for chronic tonsillitis. METHODS: After removal of both tonsils the tonsillar fossa randomly assigned to the treatment protocol was coated with fibrin glue. The other side was left unaltered. The patient was then monitored for postoperative bleeding and wound healing, and a patient-based pain assessment instrument was used to evaluate symptoms every 8 hours for 10 days after surgery. RESULTS: Detailed evaluation of the pain scores allowed the authors to create a pain profile for what the typical patient experiences over the first 10 postoperative days, as well as during the course of a single day. The pain remains relatively constant for the first 7 days and begins to decrease only on the eighth postoperative day. During a single day there is increased pain in the morning compared with noon and evening. However, no statistically significant difference was detected in postoperative pain, bleeding, or healing between the wounds treated with fibrin glue and controls. CONCLUSIONS: The patient-based pain evaluation data should aid the physician in preoperative outcome counselling and targeted prescription of pain medication. However, contrary to previous indications, the authors cannot substantiate a significant beneficial effect of fibrin glue in postoperative pain control. Furthermore, we did not find its action as a hemostatic agent clinically applicable in this setting, and thus find no indication for the routine use of fibrin glue in tonsillectomy.

Adolescent↗

PubMed2000

Tonsillectomy as a treatment of obstructive sleep apnea in adults with tonsillar hypertrophy.

OBJECTIVES: High surgical success rates for adenotonsillectomy in children with sleep-related breathing disorders have been described in various studies. The purposes of the present study were to observe how often a substantial tonsillar hypertrophy is associated with obstructive sleep apnea (OSA) in adults and to evaluate the efficiency of a bilateral tonsillectomy. STUDY DESIGN: Data from a prospective study with 11 adults who underwent tonsillectomy as single treatment for sleep-related breathing disorders were evaluated based on the severity level of their preoperative apnea-hypopnea index (AHI). MATERIAL AND METHODS: Within 3 years, 11 patients with a substantial tonsillar hypertrophy underwent attended polysomnography in the sleep laboratory. Tonsillectomy was performed, and postoperative complications and polysomnographic findings were reviewed. Follow-up time was 3 to 6 months. RESULTS: Nine of 11 patients (81.8%) were diagnosed with OSA. Five of these patients exhibited severe OSA, four patients had mild OSA, and two patients were simple snorers with an AHI below 10. The surgical response rates (defined as decrease in the postoperative AHI > or = 50% and a postoperative AHI of less than 20) were 80.0% in severe apneics and 100% in mild apneics. No serious complications occurred. CONCLUSIONS: Substantial tonsillar hypertrophy can rarely cause OSA in adults. In the carefully selected patient a tonsillectomy should be considered an effective and safe surgical option for the treatment of this disorder.

Adult↗

PubMed2001

Relief of post-tonsillectomy pain by release of lidocaine from fibrin glue.

OBJECTIVES: Pain inevitably develops after resection of the palatine tonsil (tonsillectomy). Therefore, we applied a mixture of lidocaine and fibrin glue to the tonsillar fossae immediately after tonsillectomy and evaluated its analgesic effects. STUDY DESIGN: A prospective randomized trial. METHODS: Seventy-four consecutive patients who had undergone tonsillectomy by the same surgeon (S.K.) were allocated by the sealed envelope method into three groups. After routine tonsillectomy, the operation was terminated in group A (control group), but the bilateral tonsillar fossae were covered with 1 mL fibrin glue using CaCl2 as solution to dissolve thrombin in group B and using 4% lidocaine chloride instead of CaCl2 in group C. No significant difference was observed in age or sex among the three groups. Analgesic effects were evaluated in terms of the postoperative days required until the patient began to eat normally and the postoperative days on which the patient desired analgesic administration. RESULTS: The mean postoperative days until the patient began to eat normally were 4.22 in group A and 3.78 in group B, showing no significant difference, but 2.83 in group C, being significantly shorter (P <.05). The mean postoperative days on which analgesic administration was necessary were 4.56 in group A and 4.91 in group B, showing no significant difference, but 2.88 in group C, being significantly shorter (P <.05). CONCLUSION: This method can be readily performed, requires no special treatment, and appears to have adequate pain-relieving effects.

Adult↗

PubMed2003

Invasive group A streptococcal infection after tonsillectomy.

Tonsillectomy is a very common procedure in childhood. Infectious complications after tonsillectomy are infrequently reported. We describe two children with severe group A beta-hemolytic streptococcal infection after tonsillectomy, and we review the literature about bacteremia and infectious complications after tonsillectomy.

Anti-Bacterial Agents↗

PubMed2005

Ligasure versus cold knife tonsillectomy.

OBJECTIVE: To assess parameters related to ligasure tonsillectomy (LT) versus cold knife tonsillectomy (CKT) procedure. STUDY DESIGN: Prospective randomized study. METHODS: A prospective study was conducted on 200 consecutive adult patients undergoing tonsillectomy. Indications included chronic tonsillitis and obstructive sleep apnea syndrome. Patients undergoing adenoidectomy, or any procedure together with tonsillectomy, and patients with peritonsillar abscess history or bleeding disorders were excluded. Patients were randomly assigned to either the LT or CKT group. Intraoperative bleeding, operative time, postoperative pain using a visual analogue scale, and complication rates were evaluated. RESULTS: The LT and CDT groups consisted of 108 and 92 individuals, respectively. In the LT group, there was no measurable intraoperative bleeding, whereas mean bleeding for CKT group was 125 mL. The mean operative time was 15 +/- 1.43 minutes for the LT group and 21 +/- 1.09 minutes for the CKT group (P < .001). The overall mean pain score for the LT group was 3.63, whereas for the CKT group it was 5.09 (P < .001). Primary hemorrhage occurred in one subject of the CKT group. Secondary postoperative hemorrhage was noticed two subjects of the LT group and two subjects of the CKT group. In 21 subjects of the LT group, limited peritonsillar edema was noticed. No other complication occurred in both groups. CONCLUSION: LT procedure provides sufficient hemostasis, lower postoperative pain, and reduced operative time, as well as safety against Creutzfeld Jakob disease transmission.

Adolescent↗

PubMed1997

The effect of glossopharyngeal nerve block on pain after elective adult tonsillectomy and uvulopalatoplasty.

This controlled, randomised, double-blind study compared whether glossopharyngeal nerve block and intravenous morphine administered peri-operatively, decreased pain following elective adult tonsillectomy and uvulopalatoplasty more than morphine alone. Sixteen of 30 patients undergoing uvulopalatoplasty and 38 of 78 patients having tonsillectomy received bilateral glossopharyngeal nerve blocks, using bupivacaine 0.5% and adrenaline 1:200,000, or no intervention. There were no differences in postoperative analgesic consumption between the two groups. Visual analogue pain scores measured during swallowing in the recovery room and on the ward postoperatively were significantly less overall in uvulopalatoplasty patients who had received a block (p = 0.004). This difference was not found for tonsillectomy. We found no significant differences between groups, in pain scores recorded during the first 5 days at home. We conclude that glossopharyngeal block does not improve analgesia following tonsillectomy although there is short-lived benefit following uvulopalatoplasty.

Adult↗

PubMed1991

Pain relief after tonsillectomy in adults: intramuscular diclofenac and papaveretum compared.

A wide variety of surgical and pharmacological methods have been described in an attempt to reduce pain after tonsillectomy, with conflicting results. Opiates are still widely used, despite unwanted side-effects. Recently the non-steroidal anti-inflammatory drugs have been shown to be effective against a variety of post-operative pains. Diclofenac is effective in both children and adults in the relief of pain after tonsillectomy when administered rectally, but absorption is variable, and suppositories are not widely accepted in the UK. The present double-blind study compared a single intramuscular dose of diclofenac with papaveretum in adults undergoing tonsillectomy. Post-operatively, the patients who received diclofenac had less pain and started drinking significantly sooner than the control group. There were no undesirable side-effects. Intramuscular diclofenac is superior to papaveretum in the relief of pain in adults undergoing tonsillectomy.

Adolescent↗

PubMed1992

A randomized comparison of three post-tonsillectomy diets.

Traditionally, soft cold foods have been recommended after tonsillectomy to aid comfort and haemostasis but, more recently, rougher foods have been advocated to promote physiologically normal deglutition. This trial was designed to discover whether post-tonsillectomy dietary advice has any influence on recovery. 150 patients due to undergo tonsillectomy were prospectively randomized to 1 of 3 diets: mainly rough food, mainly soft food, and no advice except to eat regularly. Food consumption, analgesia intake and pain levels were recorded daily by each patient. Tonsillar fossa slough and secondary haemorrhage were evaluated 1 and 2 weeks after surgery. Results of 137 patients were obtained. There were no significant differences between the diets regarding post-operative pain, analgesic required, healing rates or secondary haemorrhage. Specific post-tonsillectomy dietary advice need not be given, other than to encourage regular eating.

Adolescent↗

PubMed1994

The effect of fibrin sealant haemostasis on post-operative pain in tonsillectomy.

Pain following tonsillectomy is an important problem. It is caused by the surgical trauma of excision and haemostasis. Numerous surgical and pharmacological solutions have been tried, with disappointing results. Fibrin sealant is a widely used atraumatic haemostatic agent. This study aims to determine whether tonsillectomy with fibrin sealant haemostasis results in less post-operative pain than that with the conventional technique of diathermy. Fifty consecutive adult patients undergoing tonsillectomy were prospectively studied. They were randomized to receive either fibrin sealant or diathermy haemostasis. Other pain variables were controlled. Pain was measured by a visual linear analogue scale and inter-incisor distance on both the day of operation and the first post-operative day. The patients and pain measurer were blind to the randomization. The results showed that tonsillectomy with fibrin sealant haemostasis was significantly (P < 0.05) less painful than that with diathermy on both days studied and by both methods of pain measurement.

Adolescent↗

PubMed1996

Day-case tonsillectomy--is it appropriate?

There is continued encouragement to increase the use of day surgery. Recent publications have suggested that day-case tonsillectomy is a safe procedure due to the low primary haemorrhage rates (0.14-3.5%). One of the suggested benefits of day surgery is that patients want it. They prefer to recover at home after an operation. With tonsillectomy, personal experience suggested that this was not the case. A review of 117 patients having tonsillectomy was undertaken. All patients stayed in for at least one post-operative night. No patients or parents thought that the post-operative stay was too long (80% 'just right', 20% 'too short') and only 7% would have been happy to go home on the day of operation. 'Safety' does not automatically make an operation suitable for day-case surgery. Pain, nausea, vomiting, drowsiness and anxiety about the operation and post-operative course were all reasons given for not wanting to go home on the day of surgery. The justification for the increased use of day surgery is that it increases efficiency by reducing costs per case while maintaining the quality of care. One aspect of quality of care is patient acceptability and before day-case tonsillectomy is acceptable to patients the factors responsible for the post-operative morbidity need to be addressed.

Adult↗

PubMed2005

Double-blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain in children.

OBJECTIVES: The purpose of this study was to establish if children experienced any difference in pain, between coblation tonsillectomy and coblation tonsillotomy. DESIGN: A double-blind randomized controlled trial was performed. SETTING: District general hospital department of Otolaryngology. PARTICIPANTS: Eighteen children listed for tonsillectomy were recruited into the study. Each was randomly assigned either tonsillotomy or tonsillectomy in the right tonsil. The contralateral tonsil was removed by the other method. In the first 24-h period (while in hospital) the children were interviewed at 2, 5, 10 and 24 h to quantify the pain they perceived in right and left sides. There was a four point visual analogue scoring system for monitoring pain. The power of the study was 80%. In this study the patients were their own controls. MAIN OUTCOME MEASURES: Visual analogue pain scores were plotted against time and the area under the curves was calculated (AUC). RESULTS: The AUC mean difference was 0.47. A t-test for the difference gives a P-value of 0.85 and a 95% confidence interval for difference is -0.79 to 5.73, which clearly contains zero. Using AUC as a combined pain score there is no statistically significant difference between tonsillotomy and tonsillectomy (power value of 80%). CONCLUSIONS: There is no demonstrable statistical difference between techniques when measuring pain experienced by children in the 24-h postoperative period.

Acute Disease↗

PubMed2006

Patient satisfaction with NHS elective tonsillectomy outsourced to the private sector under the Patient Choice Programme.

RATIONALE, AIMS AND OBJECTIVES: An interim goal of the NHS 'Extending choice for patients' initiative was that, by 2004, patients who had been on the NHS waiting list for elective surgery for 6 months were provided with a choice of staying on the waiting list or being treated faster by opting to have their operation with an alternative provider. The aim of this study was to examine patient satisfaction in a cohort of patients who travelled out-of-region to undergo routine tonsillectomy performed by an NHS consultant at a private hospital. METHOD: A questionnaire survey was conducted of adult patients undergoing elective tonsillectomy in 2002 and 2003 at The Hampshire Clinic, Basingstoke, UK. RESULTS: Our results showed that 95% (n = 123) of patients were happy to travel considerable distances from their local hospital to have their operation. Overall 71% (n = 92) of patients rated the overall experience of having the operation performed at the private hospital as excellent and 25% (n = 32) rated it as satisfactory. CONCLUSION: We conclude that tonsillectomy performed by a consultant in an out-of-region private hospital is associated with a high level of patient satisfaction and is an acceptable way to reduce waiting times for tonsillectomy provided clear guidelines and safeguards are in place.

Adult↗

PubMed1998

Analgesic efficacy and safety of preoperative versus postoperative ketorolac in paediatric tonsillectomy.

BACKGROUND: Tonsillectomy is a common procedure in childhood resulting in significant morbidity due to pain. The aim of this study was to evaluate the analgesic efficacy and safety of a single dose of ketorolac i.v. given before or after tonsillectomy, compared to placebo. METHODS: A randomized, double-blind, placebo-controlled study was performed in 60 children, 5 to 15 years of age, admitted for tonsillectomy. Patients were allocated to receive ketorolac 1 mg.kg-1 i.v. or placebo. Postoperative pain was assessed by self-report 1.5, 3, 5, and 24 h after surgery. RESULTS: Pain scores were significantly lower for both ketorolac groups compared to the placebo group 1.5, 3, and 5 h after surgery (P = 0.05). Pain scores were lowest in the preoperative ketorolac group 1.5 to 5 h after surgery, and significantly fewer children in this group had fentanyl 0 to 1.5 hr after surgery. But no significant differences were found between pain scores of the preoperative and postoperative ketorolac groups in the first 24 h after surgery. Acetaminophen consumption during the first 5 h after surgery was significantly less in patients receiving ketorolac (P < 0.05). Patients in the preoperative ketorolac group had a significantly lower incidence of postoperative vomiting (P < 0.05). There were no significant differences in the incidence of postoperative bleeding between groups. Three children in the preoperative, 5 children in the postoperative ketorolac group and 5 children in the placebo group experienced postoperative haemorrhage. CONCLUSION: This study indicates that a single dose of ketorolac 1 mg.kg-1 i.v. administered either before or immediately after surgery improves postoperative analgesia in children after tonsillectomy without evidence of increased incidence of bleeding.

Acetaminophen↗

PubMed2004

Propacetamol and diclofenac alone and in combination for analgesia after elective tonsillectomy.

BACKGROUND: Diclofenac and paracetamol have different mechanisms and sites of action. Therefore, we tested if their combination is more effective for analgesia after tonsillectomy than either drug alone with respect to rescue analgesic consumption and visual analog scale values. METHODS: The analgesic effects of intravenously administered propacetamol (injectable pro-drug of paracetamol) and diclofenac or a combination on postoperative pain were compared in 71 adult elective tonsillectomy patients in a randomized, double-blind study. After induction of anesthesia the patients received monotherapy with 2 g propacetamol (n = 25) or 75 mg diclofenac (n = 25), or a combined treatment with 2 g propacetamol and 75 mg diclofenac (n = 21) in physiologic saline as an infusion. Postoperatively the propacetamol dosage was repeated twice and diclofenac once on the ward. Oxycodone (0.03 mg kg(-1)) was used as a rescue analgesic by patient-controlled analgesia. RESULTS: On average the patients needed oxycodone 15.3, 13.2 and 10.6 times in the propacetamol, diclofenac and combination groups, respectively (NS). A verbal rating scale and a visual analog scale were employed for assessing post-tonsillectomy pain, nausea and patient satisfaction in all groups. No statistically significant differences were found between the groups. Twelve of the 25 (48%) patients having received propacetamol complained of pain at the cannulation site. CONCLUSION: Combined treatment with propacetamol and diclofenac with the dosages used provided clinically only a minor advantage over monotherapy with propacetamol or diclofenac with respect to postoperative analgesia or the incidence of side-effects in adult tonsillectomy patients.

Acetaminophen↗

PubMed2006

Ketoprofen and tramadol for analgesia during early recovery after tonsillectomy in children.

BACKGROUND: Pain following tonsillectomy is often intense. Nonsteroidal anti-inflammatory drugs and opioids are effective, but both can cause adverse effects. Tramadol may be a viable alternative for post-tonsillectomy pain. This study was designed to compare the analgesic effects of ketoprofen and tramadol during the early recovery period after tonsillectomy. METHODS: Forty-five ASA class I children (9-15 years) were randomized to receive either saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)) after induction of anesthesia. Upon completion of surgery, the study treatment was continued as a 6 h intravenous (i.v.) infusion of another dose of saline, ketoprofen (2 mg.kg(-1)) or tramadol (1 mg.kg(-1)). Postoperatively, each patient received rescue analgesia with patient-controlled analgesia (PCA) device programmed to deliver 0.5 microg.kg(-1) bolus doses of fentanyl. Postoperative pain was assessed using Visual Analog Scale (VAS) during swallowing. Intraoperative blood loss was measured. RESULTS: The total number of requests of PCA-fentanyl was significantly less in ketoprofen group compared with tramadol and placebo groups (P = 0.035 and P = 0.049, respectively, in pairwise comparisons) and the VAS scores for pain were significantly lower in ketoprofen group compared with tramadol (P = 0.044) or placebo groups (P = 0.018) during the first six postoperative hours. Measured intraoperative blood loss was greater in ketoprofen-treated patients than in those receiving placebo (P = 0.029). CONCLUSION: A dose of 4 mg.kg(-1) of i.v. ketoprofen provided good pain relief with moderate supplemental PCA-fentanyl requirements during the first six postoperative hours after tonsillectomy in children whereas the effects of 2 mg.kg(-1) of i.v. tramadol did not differ from those of placebo.

Adolescent↗

PubMed2006

Effect of an intravenous single dose of ketamine on postoperative pain in tonsillectomy patients.

BACKGROUND: Tonsillectomy has a high incidence of postoperative pain. The aim of the present study was to determine whether the use of low-dose IV ketamine, before the start of surgery or after the end of the operation, would lead to significantly improved pain control after tonsillectomy in pediatric patients. METHODS: Ninety children, 5-7 years old, scheduled for elective tonsillectomy were randomly assigned to one of three groups of 30 patients each; groups I, II and III. Patients in group I received no ketamine. Patients in group II received 0.5 mg x kg(-1) of ketamine before the surgical start and for group III the same dose was given after the operation ended. Postoperative pain was scored by the Oucher scale. Systolic and diastolic pressures and heart rate were recorded perioperatively. Unwanted side effects were recorded by the ward staff personnel on a 24-h study-specific questionnaire. Statistical tests consisted of Student's t-test, chi-square and anova as appropriated. RESULTS: The number of patients complaining of pain was greater in group I compared with patients in groups II and III with a significative statistical difference (P < 0.05). The degree of postoperative pain was significantly higher in patients of group I compared with groups II and III (P < 0.05). Eight patients in group I needed rescue doses of morphine, three for group II and none for group III. In group I, three of eight patients required two doses of morphine during the first 249 h postoperatively. No unwanted side effects were noted. CONCLUSIONS: The use of a single small dose of ketamine in a pediatric population undergoing tonsillectomy could reduce the frequency or even avoid the use of rescue analgesia in the postoperative period independent of whether used before or after the surgical procedure.

Analgesia↗