Tonsillectomy: cold dissection versus bipolar electrodissection

OBJECTIVES: to compare the technique and post-operative morbidity of two different tonsillectomy methods: cold dissection and bipolar electrodissection. MATERIAL AND METHODS: prospective study including children (3> age <14) undergoing tonsillectomy in ORL Department of the main hospital in Azores, Portugal, from September 2000 to March 2001. Patients alternately selected to cold dissection tonsillectomy group (CDT) or bipolar electrodissection tonsillectomy group (BET). Duration of surgery; amount of blood loss; duration of hospitalization; aspect of tonsillar fossa on 10th post-operative day and intensity of pain after surgery were recorded and compared. RESULTS: Sixty tonsillectomies were performed. Blood loss and duration of surgery were significantly decreased in BET group (P<0.001), but the healing process, directly assessed by the aspect of tonsillar fossa on the 10th day was markedly delayed. The intensity of pain was slightly higher in the BET group compared with the CDT group, and no difference on duration of hospitalization was found between the two groups. Two post-operative hemorrhages occurred (one in each group), and no major complications were registered. CONCLUSIONS: BET reduces the duration of surgery and amount of blood loss when compared with cold dissection, but post-operative morbidity is increased. We believe the best patient indication for this method are small children where total circulating blood volume is reduced and patients with bleeding disorders.     

Role of Bupivacaine in reducing post tonsillectomy pain

Pain following tonsilleclomy is of major concern to both the surgeons and the Anesthesiologists. Pre-incisional Bupivacaine infiltration into the tonsillar fossa has been used as a method of relieving post-operative pain in children. In this study pre-incisional Bupivacaine infiltration into the tonsillar fossa resulted in immediate post-operative pain lasting four to six hours.     

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

OBJECTIVE: To compare the administration of bupivacaine hydrochloride, dexamethasone and lidocaine hydrochloride in decreasing post-tonsillectomy pain. METHODS: Eighty patients were enrolled in the study in ENT Clinic, Firat University, and in ENT Clinic Elazi? SSK Hospital, Elazi? (Turkey). Children between 6 and 14 years of age referred to our department for bilateral tonsillectomy for either recurrent tonsillitis or tonsillar hypertrophy. Data from 80 patients were analyzed. The first group had bupivacaine hydrochloride. The second group had dexamethasone infiltrated around each tonsil. The third group was given equal doses of 10% lidocain hydrochloride sprayed on the tonsillectomy fossa four times a day, and a placebo group received 9% NaCl applied to the tonsillar fossa four times a day. Pain scores, determined by visual analog scale, were obtained in the first, third and seventh postoperative days. RESULTS: Pain scores in the postoperative period were identical in the first, third and seventh postoperative days. According to VAS results the groups were compared on the basis of postoperative pain. In the first postoperative day, the difference between bupivacaine-placebo, dexamethasone-placebo and lidocaine-placebo groups was found to be statistically significant (P<0.05). Nevertheless the difference between bupivacaine-dexamethasone, bupivacaine-lidocaine and dexamethasone-lidocaine were not significant (P>0.05). In the third postoperative day, the difference between bupivacaine and lidocaine group found to be statistically significant (P<0.05). In the seventh post-operative day the results of bupivacaine, dexamethasone, lidocaine and placebo groups were similar (P>0.05). CONCLUSION: Bupivacaine, Dexamethasone and Lidocaine nasal aerosol decreased the pain significantly in the first postoperative day when it was compared with the placebo group. These three medicines can be used to reduce pain for children during the postoperative period applied tonsillectomy during the post-operative period. But lidocaine was more preferable, reducing pain in the third postop day better than bupivacaine.     

Does cooling the tonsillar fossae during thermal welding tonsillectomy have an effect on postoperative pain and healing?

The objective of this study was to evaluate the effect of cooling the tonsillar fossa during thermal welding tonsillectomy on pain and wound healing. Prospective, blinded, clinical study was conducted. 30 patients who underwent tonsillectomy by thermal welding were evaluated. When one of the tonsillar fossa was cooled by isotonic fluid, the other has left untreated. Postoperative pain and mucosal healing pattern were assessed. Data were recorded and statistically analyzed. Healing process of the cooled down tonsillar fossae were significantly better on the 7th and 14th postoperative day (p < 0.01). Control tonsillar fossae had significantly higher pain scores on the 3rd, 7th and 14th postoperative day (p < 0.05). Administration of isotonic fluid, during thermal welding tonsillectomy for cooling tonsillar fossae, accelerates wound-healing process significantly and decreases tonsillectomy related pain complaints post-operatively.     

Can post-tonsillectomy pain be reduced by topical bupivacaine? Double blind controlled trial

A double blind controlled prospective trial investigated the analgesic effect of topical Bupivacaine in 15 adult patients undergoing bilateral tonsillectomy. Each patient had one tonsillar fossa exposed to Bupivacaine 0.5 per cent solution and the other to normal saline. When visited four to six hours post-operatively, 12 out of 15 patients (80 per cent) stated that the Bupivacaine exposed side to be more uncomfortable than the saline exposed side. On the first post-operative morning 9 out of 15 patients (60 per cent) confirmed the same. The remaining patients were unable to detect a significant difference and no patient found the Bupivacaine side to be more comfortable. These results suggest that topical Bupivacaine 0.5 per cent solution has no place in providing post-operative analgesia in adult tonsillectomy.     

Effect of cold-water cooling of tonsillar fossa and pharyngeal mucosa on post-tonsillectomy pain

Purpose

Post-tonsillectomy pain is a notable concern and thermal injury produced by electric surgical devices is considered a main cause. Intraoperative cooling of the tonsillar fossa and pharyngeal mucosa with cold water has effectively reduced postoperative pain, but no studies have fully evaluated the effects of this technique with a proper study design. We assessed mucosal cooling in two groups of patients undergoing the same surgical technique by a single surgeon, with one group receiving cold-water cooling and the other group as a control.

Methods

Forty patients who underwent monopolar electrocautery tonsillectomy were randomly assigned to two groups (n = 20 for each group). Group 1 received cooling of the tonsillar fossa and pharyngeal mucosa with 4 °C saline just after removal of each tonsil whereas Group 2 did not receive cooling. Postoperative pain was recorded on operation day and 1, 2, 4, 7, and 10 days postoperatively. Post-tonsillectomy pain, return to normal diet, and incidence of postoperative bleeding were compared between the groups.

Results

Post-tonsillectomy pain on 6 selected days and overall pain during the 10-day follow-up period were significantly lower in Group 1. However, return to normal diet and incidence of postoperative bleeding did not differ significantly between the groups.

Conclusions

Intraoperative application of cold water after tonsillectomy significantly reduced postoperative pain. We recommend cooling the tonsillar fossa and pharyngeal mucosa with cold water during tonsillectomy to easily and effectively reduce post-tonsillectomy pain.     

Preincisional infiltration of tonsils with ropivacaine in post-tonsillectomy pain relief: double-blind, randomized, placebo-controlled intraindividual study

OBJECTIVE: To determine whether pre-emptive ropivacaine has an influence on postoperative pain in adult patients undergoing tonsillectomy. DESIGN: A prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: University hospital. PATIENTS: The study included 20 adult patients undergoing elective tonsillectomy. Anesthetic induction and maintenance, dissection tonsillectomy, hemostasis techniques, and postoperative analgesic treatment were standardized for all patients. Before the onset of incision, one tonsillar fossa was administered 5 mL of 2% ropivacaine hydrochloride with epinephrine, whereas the other side received 5 mL of 0.9% saline with epinephrine and was designated as the control side. MAIN OUTCOMES MEASURES: For each side, postoperative pain, otalgia, operating time, amount of intraoperative blood loss, and postoperative hemorrhage were assessed. The intensity of postoperative pain was measured at rest and when the patient was drinking and was scored on a visual analogue scale. The patients were followed up for 10 days after surgery. RESULTS: There was no statistically significant difference in the amount of intraoperative hemorrhage and operation time between sides (p > .05). The constant postoperative pain in the ropivacaine side at rest was significantly less than in the placebo side on days 1, 2, 5, and 6 (p < .05). The post-tonsillectomy pain experienced in the ropivacaine side when swallowing was significantly less than that in the placebo side throughout the study period except on day 10 (p < .05). CONCLUSION: Based on the present findings, preincisional infiltration of ropivacaine 2% appears to be effective against both early and late postoperative pain, especially on swallowing, following tonsillectomy in adults.     

Evaluation of bismuth subgallate and adrenaline paste as haemostat in tonsillectomy bleeding

Haemorrhage is a frequent and often feared complication of tonsillectomy. This has prompted the use of a variety of topical haemostatics such as bismuth subgallate to achieve haemostasis and reduce the risk of postoperative haemorrhage. In this study effect of bismuth subgallate and adrenaline paste was investigated. A total of twenty five subjects undergoing tonsillectomy were randomly recruited. The distinctive feature of study was that each patient constituted a matched pair, with left tonsillar fossa acting as control and right tonsillar fossa as trial side. Bismuth subgallate adrenaline paste was made by mixing 13 gm of Bismuth subgallate powder with 10 ml of normal saline and 0.35 ml of 1: 1000 adrenaline. The application of twin reagent paste resulted in reduced blood loss in trial fosse (60.8 ± 19.3 ml) as compared to control fossa (91.2 ± 20.27) (p < 0.0001). Similarly the average number of ligatures applied to control bleeding was also less in trial fosse. Only one patient reported reactionary haemorrhage while there was no report of secondary haemorrhage from amongst tonsillar fosse on trial side. However, two patients presented with secondary haemorrhage from control side fosse.     

Tonsillotomy with the argon-supported monopolar needle--first clinical results

BACKGROUND: Primary management of tonsillar hyperplasia in children is tonsillectomy. Recent data from clinical case-series are clearly in support of the hypothesis that tonsillotomy with the CO2-laser seems to be effective and is noted to have less postoperative bleeding and less pain as compared to tonsillectomy. For the first time we used a monopolar argon-supported needle for tonsillotomy in the following study. METHODS: Fifty patients (age: 4.58 years; SD +/- 2.33) with benign tonsillar hyperplasia were recruited. For tonsillotomy we used the monopolar argon-supported needle. The outcome measures were postoperative pain, capability of oral intake, consumption of analgesics and postoperative bleeding. RESULTS: No postoperative bleeding occurred. Post-operative pain hardly occurred and could easily be controlled. The third postoperative day analgesics intake was under one portion per day (mean: 0.91; SD +/- 1.26). Capability of oral intake and swallowing was normal on the seventh postoperative day. CONCLUSION: It was concluded that tonsillotomy, using the monopolar argon-supported needle, is a valid treatment for benign tonsillar hyperplasia in children, which can be performed with slight post-operative pain and a low risk for postoperative bleeding. It offers good dissection and haemostasis abilities. Compared to the CO2-laser the monopolar argon-supported needle does not require any laser safety precautions.     

Topical application of ethanol to the tonsillar bed immediately following tonsillectomy does not improve post-operative analgesia

Tonsillectomy is a painful procedure with discomfort continuing for days after the operation. We investigated whether topical application of a neurolytic agent (ethanol) to the tonsillar bed following dissection could provide long-term analgesia. Sixty-four patients undergoing tonsillectomy were randomized using matched pairs, to receive topical ethanol applied to the operative site, or saline for three min, in a double-blind study. Endpoints included self-reported pain using a pictorial pain scale, analgesia consumption adjusted for body mass, and weight loss. Follow-up continued until day 7 post-operatively. Both groups received the same analgesic protocol including infiltration of the operative site with ropivacaine. There were no significant differences in pain scores, analgesia requirements or weight loss between groups for any time period. The incidence of severe pain was significantly greater on the third post-operative day compared with day 1 and 2 (p = 0.0096). Topical application of ethanol does not reduce post-operative pain.     

Can mucosal sealing reduce tonsillectomy pain?

OBJECTIVE/HYPOTHESIS: The hypothesis tests whether sealing the tonsillectomy field with posterior pillar mucosa can prevent unwanted outcomes in pediatric tonsillectomy. STUDY DESIGN: A prospective, randomized, single blinded study was conducted on a sample of 39 children between 3 and 15 years of age. After dissection and snare tonsillectomy, the tonsillar fossa was covered on one side using the palatopharyngus mucosa and the other side is used as control. Pain scores, healing, edema and infection at the operation site were investigated. METHODS: The tonsillectomy sites were randomly assigned into one of two groups. First group contained the ones with mucosal flap sealed over the operation site and the second group was kept as control with the operation site left uncovered. All of the patients received mild analgesics. The pain assessment is done on Days 1, 3, 5, 7 and 10 postoperatively, by using Wong-Baker faces visual analog scale. On the 10th postoperative day, the operation field of each side is scored separately for edema, healing and infection. Statistical investigation was performed through a software program. RESULTS: On first postoperative day, pain level difference was not statistically significant between the two groups (p>0.01). But from 3rd to 10th postoperative day, the pain level was found out to be lower in the mucosa sealed site (p<0.01). On the 10th postoperative day, while the edema was significantly more (p<0.01), healing was better (p<0.01) at the sutured site. Postoperative infection at operation site was not different between the groups (p>0.01). CONCLUSION: Covering tonsillectomy field with mucosal palatopharyngeal arch flap significantly reduces pain after third postoperative day. The flap side had better healing when compared to denuded site. But the sutures in the mucosal flap may cause more tissue edema. Sutures have no significant effect on postoperative infection. Thus, mucosal flap may be used as an adjuvant surgical technique to decrease tonsillectomy pain of children in addition to the analgesic medication.     

Coblation tonsillectomy: a double blind randomized controlled study

Tonsillectomy has been performed by a number of techniques. This double blind randomized controlled study compares the technique of tissue coblation with bipolar dissection for the removal of tonsils in 10 adult patients with a history of chronic tonsillitis. A significant reduction in post-operative pain and more rapid healing of the tonsillar fossae were found in the side removed by tissue coblation. There were no episodes of primary or secondary haemorrhage on either side. This new technique for tonsil removal warrants further study.     

Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy

Objectives

To review our experience with intracapsular tonsillectomy using powered instrumentation (PIT) in the management of tonsillar hypertrophy.

Design

Retrospective database review of pediatric patients undergoing PIT.

Methods

The medical records of 636 patients under 11 years of age who underwent PIT performed by the senior author (RFW), predominantly for obstructive sleep disturbance, were reviewed. Data were subsequently analyzed from 559 of these patients for clinical evidence of tonsillar regrowth, post-operative tonsillar hemorrhage, and post-operative dehydration due to pain. Specific information for possible correlation of age at the time of surgery and any increased rate of regrowth was primarily examined.

Results

There were a total of 33 patients who had clinical evidence of regrowth. Children less than 5 years of age had 5 times the incidence of regrowth (p < 0.001). Out of the group that exhibited regrowth, 5 patients exhibited evidence of recurrent upper airway obstruction and underwent a complete tonsillectomy. The age of this complete tonsillectomy group ranged from 1.1 to 2.7 years. Out of all patients undergoing PIT, there was 1 incident of delayed post-operative dehydration due to emesis but not due to pain. There were 2 incidents of delayed post-operative tonsillar bleeds. All three complications were self-limited and did not require re-hospitalization.

Conclusions

PIT is a safe procedure with a small risk of tonsillar regrowth being age related. The incidence of postoperative complications following PIT is relatively low (0.54%).     

Effect of bupivacaine on pain after tonsillectomy: a randomized clinical trial.

Several authors have found that pre-incisional injection of local anaesthetics reduces postoperative pain. In the present double-blind study, comprising 126 inpatients aged 6-42 (mean 19) years, we investigated whether pre-incisional injection of bupivacaine during general anaesthesia reduces the pain experienced after tonsillectomy. The patients were randomized into three treatment groups: 43 patients were injected with 5 ml of bupivacaine (2.5 mg/ml)+ epinephrine (5 microg/ml) solution in both tonsillar fossa, 41 had epinephrine (5 microg/ml) + saline (9 mg/ml) and 42 patients received saline (9 mg/ml) only. Self-assessment of pain during the first postoperative week (repeated measures) was recorded. Use of analgetics, experience of the surgeons, peroperative bleeding and several other clinical parameters were assessed. Analyses of covariance with repeated measures was carried out for each pain score. In general there was no statistical significant difference in pain scores, represented by a visual analogue scale (VAS) between the three treatment groups. However, injection of bupivacaine into the tonsillar fossa seemed to reduce pain shortly after the operation in the age group 19-24 years. Further, females and older patients reported more pain and used more analgetics than males and younger patients. Increasing experience of the surgeon was related to a lower score for baseline pain shortly after the operation. Epinephrine in bupivacaine or saline reduced peroperative bleeding. We conclude that bupivacaine does not provide significant postoperative analgesia after tonsillectomy in an unselected group of patients.     

Candida infection after tonsillectomy in a 12-year-old girl

Tonsillectomy has been associated with complications such as bleeding, pain, dehydration, edema, airway obstruction, atlantoaxial subluxation and infection. However, fungal infection is a very rare complication of tonsillectomy. We describe the case of a 12-year-old girl who developed oral Candida infection as a complication of tonsillectomy. She had pain and difficulty in swallowing on the third postoperative day, and a local examination revealed an easily grazing, white plate on the tonsillar fossa. A culture of the lesion tissue identified Candida albicans. Local nystatin therapy was administered, and the lesion healed completely by postoperative day 12. We conclude that fungal infection, though rare, can occur as a complication of tonsillectomy.     

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     

Pediatric coblation total tonsillectomy: intracapsular or extracapsular?

Objectives: To compare the results of coblation intracapsular total tonsillectomy (CITT) with those of conventional coblation extracapsular total tonsillectomy (CETT) in the treatment of tonsillar hypertrophy in children with regards to efficacy and complications.

Methods: Ninety children with adenotonsillar hyperplasia underwent tonsillectomy?±?adenoidectomy (48 CITT and 42 CETT). Intraoperative situation was observed and recorded. Patients were reexamined regarding recovery condition and tonsil regrowth, and were followed for at least one year.

Results: Significant differences were observed in four clinical features when the CITT group was compared with the CETT group: intraoperative bleeding score, intraoperative tonsillar fossa score, color of white membrane one day postoperatively, and visual analogue scale (VAS) value one week postoperatively (p?p?p?Conclusions: Compared with conventional extracapsular tonsillectomy, CITT has the advantages of decreased pain and bleeding, and promote healing of wounds. No tonsillar regrowth was observed after at least one year of follow-up.     

Fusafungine after tonsillectomy

BACKGROUND: Postoperative period after tonsillectomy is characterized by inevitable discomfort for the patient. The aim of the study was to estimate whether fusafungine in spray has an effect on healing process after the operation, especially on pain and consumption of analgesics. PATIENTS: A prospective open, randomized study was performed on 68 patients (age 15 - 55) undergoing tonsillectomy for chronic tonsillitis. Except of standard postoperative therapy 34 patients received fusafungine in spray 4 times daily and 34 patients served as a control. Pain score in the morning and in the evening, consumption of analgesics and visual estimation of wound healing in the tonsillar fossa was evaluated. RESULTS: Fusafungine in spray significantly reduces pain in the early days (2 - 4 day) after the operation and offers almost 16 % decrease in total consumption of analgesics (p < 0.04). Despite of that, total evaluation of pain score shows no significant differences in the both groups. The observation of wound healing suggests better cleanliness in 25 % of patients after fusafungine. CONCLUSION: Fusafungine in spray improves quality of life after the tonsillectomy and so completes the spectrum of adjuvant postoperative local treatment possibilities.     

Localization of the carotid artery within the tonsillar fossa by Doppler flow mapping

Injury to the internal carotid artery during procedures performed in the tonsillar fossa can be catastrophic. Tonsillectomy or uvulopalatopharyngoplasty was performed on 32 patients at the Hospital of the University of Pennsylvania or the Children's Hospital of Philadelphia. Using Doppler ultrasonography, the course of the internal carotid artery in the postsurgical tonsillar fossa was mapped. The results indicate that, in the majority of patients, the internal carotid artery is located between 20% and 60% of the total width across the tonsillar fossa, as measured from the posterior pillar. Appreciation of the surgical anatomy of the tonsillar fossa with respect to the internal carotid artery should contribute to improved intraoperative judgment and further limit the risk of vascular injury during oropharyngeal procedures.