Pre-emptive peritonsillar dexamethasone vs. levobupivacaine infiltration for relief of post-adenotonsillectomy pain in children: A controlled clinical study

Objectives

To investigate the effects of the pre-emptive local infiltration of dexamethasone vs. levobupivacaine on postoperative pain and morbidity in pediatric adenotonsillectomy patients.

Methods

A total of 60 patients (32 males and 28 females), aged 3–14 years, were included in this double-blind prospective randomized controlled clinical study from September of 2011 until May of 2012. Patients admitted for adenotonsillectomies after informed consent was obtained from the parents, and randomized into three groups receiving either dexamethasone sodium phosphate (Group 1, mean age 5.9 ± 1.6), levobupivacaine with epinephrine (Group 2, mean age 6.1 ± 2.6), or saline (Group 3, mean age 6.0 ± 3.4). Pain scores at the 1st, 4th, 8th, 12th, 16th, and 20th hours, and first, second, third and seventh days post-operatively were recorded by the parents using McGrath’s face scale. The operation type, operation time and anesthesia time, the time of the first request for postoperative analgesia, and the total number of analgesic interventions were recorded.

Results

Pain scores were revealed in this order: Group 1 (steroid) < Group 2 (levobupivacaine) < Group 3 (saline) at all times (p = 0.000). The anesthesia times for Group 1 and Group 2 were different (steroid vs. levobupivacaine), and the time to first analgesic was longer in Groups 1 (steroid) and 2 (levobupivacaine) than in Group 3 (saline) (p < 0.000). The total number of analgesic interventions was lower in Group 1 (steroid) than in Group 2 (levobupivacaine) and Group 3 (saline) (steroid vs. saline, p = 0.000, and steroid vs. levobupivacaine, p < 0.05).

Conclusion

Peritonsillar dexamethasone infiltration was more effective than both levobupivacaine and saline in reducing post-tonsillectomy pain. It was proven to be a safe and effective method.     

Efficacy of pillar suture for post-tonsillectomy morbidity in children: a meta-analysis

IntroductionSeveral surgical techniques have been used during tonsillectomy to reduce complications.ObjectivesTo assess the effects of pillar suture in conjunction with tonsillectomy as compared to tonsillectomy without suture in children.MethodsTwo authors independently searched five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database) for studies published as recent as December 2018. Of the included studies, we compared tonsillectomy and pillar suture in combination (suture groups) with tonsillectomy alone,without suture, (control group). Postoperative pain intensity and other morbidities (e.g., postoperative bleeding, palatal hematoma, discomfort, and pillar edema) were measured during the postoperative period.ResultsPostoperative bleeding [primary (OR = 0.47 [0.27; 0.81]) and secondary (OR = 0.14 [0.02; 0.78]) were significantly decreased in the pillar suture group compared to the control group. There were no significant differences between the two groups in postoperative pain at day 7 (SMD = −0.39 [−0.79; 0.00]), palatal hematoma (OR = 5.00 [0.22; 112.88]), palatal discomfort sensation (OR = 2.62 [0.60; 11.46]), site infection (OR = 5.27 [0.24; 113.35]), and velopharyngeal insufficiency (OR = 2.82 [0.11; 74.51]). By contrast, pillar edema (OR = 9.55 [4.29; 21.29]) was significantly increased in the pillar suture group compared to the control group.ConclusionsPillar suture combined with tonsillectomy may reduce postoperative bleeding incidence despite increasing pillar edema in pediatric tonsillectomy. Postoperative pain-relief, palatal hematoma, palatal discomfort sensation, site infection, and velopharyngeal insufficiency were not significantly altered compared to tonsillectomy alone. However, further studies are needed to corroborate the results of this study.     

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Evaluation of early postoperative morbidity in pediatric tonsillectomy with the use of sucralfate

OBJECTIVE: The objective of this study is to evaluate the efficacy of sucralfate in alleviating posttonsilectomy morbidity in a pediatric group of patients. METHODS: A prospective, double-blind, randomized, and placebo-controlled study comparing the irrigation of a solution containing either 1g of sucralfate (study group) or 1g of lactulose (control group) was performed on 69 children aged 3-12 years, who underwent tonsillectomy at the University Hospital of Brasilia Medical School. The children were randomly assigned and each one used a solution containing sucralfate or lactulose to swish and swallow four times daily during 7 days. Eleven patients were excluded. The anesthetic was standardized and no premedication was used. Pain magnitude using an "Oucher" scale, nausea, vomiting, bleeding, earache, analgesic drug intake, changes in the interincisor teeth distance, and changes in the weight and temperature were assessed by the surgeon 6, 24h, and 7 days after the surgery. RESULTS: Patients in the study group had significantly lower pain scores in the initial 6 postoperative hours (p<0.05). The difference between the two groups was not statistically significant for the other periods following the procedure or on the evaluation of the other indices. CONCLUSIONS: The use of the sucralfate in pediatric patients undergoing tonsillectomy was not effective in reducing the postoperative morbidity according to the parameters used in this study. The surgical technique with careful mucosal dissection associated with postoperative caries could be more important in the reduction of posttonsilectomy morbidity.     

Peritonsillar infiltration with tramadol improves pediatric tonsillectomy pain

Pain control in pediatric patients undergoing tonsillectomy remains a dilemma. Tramadol is reported to be an effective analgesic. This prospective, double-blinded, placebo-controlled study was performed to evaluate the analgesic efficacy and safety of submucosal infiltration of tramadol on postoperative pain in children after standard bipolar diathermy tonsillectomy. Following standard bipolar diathermy tonsillectomy was performed, 40 patients were randomized to receive submucoasl infiltration with 2 mg kg⁻¹ tramadol in 3 ml of normal saline (1.5 ml per tonsil) or normal saline only. The patients in each group were compared postoperatively with regard to the quality of pain control using the objective pain scale (OPS), sedation score and their analgesic requirements. Peritonsillar infiltration of tramadol (group 2) provided superior postoperative analgesia to placebo (group 1) for 4 h after surgery. In addition, group 1 received significantly more doses of paracetamol than group 2 in order to maintain analgesia in the first 12 h after recovery from anesthesia. Peritonsillar infiltration of tramadol appears to be an effective method of providing superior analgesia in the postoperative period when compared to placebo.     

Ketamine in post-tonsillectomy pain

OBJECTIVE: There has yet been no ideal method for postoperative analgesia in children. Ketamine demonstrates a potent analgesic effect by central blockage of perception of pain with sub-anesthetic doses. Preoperative intramuscular administration of ketamine for sedation decreases the pain during swallowing after tonsillectomy, while it provides long-term analgesia when applied around the incision. The aim of this study is to compare the effectiveness of ketamine administered to the tonsillar region following tonsillectomy for postoperative pain management. METHODS: After obtaining consent from the local ethics committee and the parents, 60 patients from the ASA groups I and II, between 3 and 7 years of age, planned for adenotonsillectomy as outpatients, were included in the study. Subjects were randomly assigned to two equal groups and 2ml 0.9% saline for group S, and 0.5mgkg(-1) ketamine and saline 2ml in volume for group K were administered into the tonsillar region. All subjects were monitored in a standard manner and SpO(2), systolic arterial pressure (SAP), and cardiac pulse rates were recorded in 5min intervals. The CHEOPS and Wilson sedation scale were used to evaluate pain levels and sedative condition, respectively. Nausea and vomiting scores of the subjects were also noted. The time of the first analgesic administration and the total amount of analgesics in an 8-hour period were recorded. Student-T and Chi-Square tests were used for the statistical evaluation of the data and a p value of <0.05 was accepted as significant. RESULTS: There were no significant differences between groups according to age, sex, weight, intermittent SAP and cardiac pulse rates. However, the CHEOPS value, the first analgesic need and the total amount of analgesic need were in favor of ketamine (p<0.05). CONCLUSIONS: In previous studies, no significant differences were demonstrated in pre-emptive analgesia with ketamine, magnesium, morphine, and clonidine. The dose of ketamin and the volume used in this study caused no sedation or nausea and provided a high level of analgesia. Ketamine infiltration into the tonsillar region after tonsillectomy was found to be easy and effective.     

地塞米松在成人扁桃体切除术后镇痛中的应用研究

目的 研究地塞米松在成人扁桃体切除术后镇痛中的应用效果。方法 选取行双侧扁桃体切除术的成人患者97例为研究对象,随机分为实验组（应用地塞米松）和对照组（不应用地塞米松组）。记录患者自手术当天至术后第6天的每日局部疼痛情况并进行评分。结果 在手术当天至术后4天,实验组的术后局部疼痛程度比对照组有较明显的减轻,差异有统计学意义;但在术后第5、6天,两组差异无统计学意义。结论 成人扁桃体切除术后应用地塞米松,可以较好地减轻手术当天至术后第4天的疼痛。     

Effects of intramuscular and peritonsillar injection of tramadol before tonsillectomy: a double blind, randomized, placebo-controlled clinical trial

BACKGROUND/AIMS: Our objective was to investigate the efficacy of intramuscular injection and peritonsillar infiltration of tramadol to prevent pain in children undergoing tonsillectomy. METHODS: In a double-blinded trial, 45 children were randomized into three groups: infiltration anesthesia with tramadol (2 mgkg(-1)) to the peritonsillar area (INF group, n=15), intramuscular analgesia with tramadol (2 mgkg(-1)) (IM group, n=15), and the placebo controls (PL group, n=15). Visual analog scale (VAS) scores for pain assessment, heart rate (HR) and mean arterial pressure (MAP) during and after anesthesia were recorded. RESULTS: Mean HR values were higher in INF than PL group at 10th, 20th, and 30th minutes of operation (P<0.05). Nine children required analgesics within the first hour after surgery in PL compared to 1 child in INF group (P=0.036). VAS scores on awakening were significantly better in INF than PL group (P=0.015). The difference between IM and PL groups was not significant for any of the parameters. CONCLUSION: Peritonsillar infiltration with tramadol provided good intraoperative analgesia, less postoperative pain on awakening and lower analgesic requirement within the first hour after surgery.     

成年人扁桃体切除术三种手术方式的临床比较

目的 比较分析成年人3种扁桃体切除术的临床应用价值。 方法 将90例行扁桃体切除术的患者分为等离子扁桃体切除术组(等离子组)、电刀扁桃体切除术组(电刀组)、常规扁桃体剥离术组(剥离组),各30例,记录各组手术时间、术中及术后出血量、术后咽痛程度、住院医疗费用等。 结果 3组手术时间、术中出血量、术后1~4 d咽痛视觉模拟量表(VAS)评分比较差异有统计学意义(P<0.001),其中等离子组和电刀组手术时间、术中出血量及VAS评分明显少于剥离组(P<0.001),而等离子组与电刀组之间差异无统计学意义(P>0.05)。剥离组术后见原发性出血1例,等离子组及电刀组未见术后出血发生。3组护理及检疗费、术后用药费比较差异无统计学意义(P>0.05);电刀组及剥离组住院总费用明显低于等离子组(P<0.001),而电刀组与剥离组比较差异无统计学意义(P>0.05)。 结论 成年人扁桃体切除术各有优势及不足,临床应根据疾病特点、患者意愿和经济能力、手术者技术水平以及医疗器械等因素选择最恰当的,从而达到最佳治疗效果。     

Comparison of bupivacaine and ropivacaine on postoperative pain after tonsillectomy in paediatric patients

BACKGROUND: We aimed to compare the effects of peritonsillar bupivacaine and ropivacaine infiltration on pain after tonsillectomy in children. METHOD: Sixty patients were randomly allocated to three groups: pertonsillar infiltration with bupivacaine (group B), ropivacaine (group R) and normal saline (group S). Pain scores with visual analogue scale (VAS) and sedation scores were assessed during postoperative 24h. Choice of additional analgesic was acetaminophen for all patients. RESULTS: VAS was significantly lower in groups B and R, during the first half hour, while it was lower in group B than those in groups R and S at postoperative second and sixth hours. Time to first analgesic treatment was significantly longer in groups B and R. Total acetaminophen consumption was lower in group B than those in group S. Sedation scores were higher in group B than in groups R and S until postoperative second hour but there were significant difference only at postoperative fifth minutes. CONCLUSION: Peritonsillar bupivacaine infiltration is, however, insufficient to control postoperative pain, it is more effective than ropivacaine for reducing postoperative analgesic requirement.     

The comparison of preincisional peritonsillar infiltration of ketamine and tramadol for postoperative pain relief on children following adenotonsillectomy

Objective

To investigate and compare the effectiveness of preincisional peritonsillar infiltration of ketamine and tramadol for post-operative pain on children following adenotonsillectomy.

Study design

Prospective randomized double blind controlled study.

Methods

Seventy-five children aged 3–10 years undergoing adenotonsillectomy were included in study. Patients received injections in peritonsillar fossa of tramadol (2 mg/kg-2 ml), ketamine (0.5 mg/kg-2 ml) or 2 ml serum physiologic. During operation heart rate, oxygen saturation, average mean blood pressures were recorded in every 5 min. Operation, anesthesia and the time that Alderete scores 9–10, patient satisfaction, analgesic requirements were recorded. Postoperatively nausea, vomiting, sedation, dysphagia, bleeding scores were recorded at 0, 10, 30, 60 min and 2, 4, 8, 12, 18, 24 h postoperatively. Pain was evaluated using modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at fixed intervals after the procedure (15 min and 1, 4, 12, 16, and 24 h postoperatively).

Results

The recordings of heart rate, mean arterial pressure, nausea, vomiting, sedation and bleeding scores were similar in all groups (p > 0.05). The mCHEOPS scores at 10 min, 30 min, 1 h, 8 h were significantly lower in both tramadol and ketamine group when compared with control (p < 0.05). Use of additional analgesia at 10 min and 18 h were higher in control group than ketamine, tramadol group (p < 0.05). Dysphagia scores were significantly lower for both ketamine and tramadol group when compared with control group (p < 0.05). mCHEOPS, additional analgesia, dysphagia, patient satisfaction scores were similar in tramadol, ketamine groups (p > 0.05).

Conclusions

Preincisional injection of ketamine and tramadol prior to tonsillectomy is safe, effective method and equivalent for post-tonsillectomy pain, patient satisfaction, postoperative nausea, vomiting, dysphagia.     

扁桃体下极被膜保留的扁桃体切除术在儿童阻塞性睡眠呼吸暂停治疗中的应用

目的 观察扁桃体下极被膜保留的扁桃体切除术在儿童阻塞性睡眠呼吸暂停(OSA)中的可行性及优势。方法 将2018年8月—2019年12月行扁桃体下极被膜保留扁桃体切除术(91例)与2017年1月—2018年7月行传统扁桃体切除术(100例)治疗儿童OSA患者的临床资料进行回顾性对比分析。比较两组手术时间、术中出血、术后疼痛评分、术后并发症、随访1年的情况。结果 两组手术时间及术中出血无明显差异,下极被膜保留组术后第1天、第3天疼痛评分显著低于传统手术组(P＜0.05)。术后出血率传统手术组(7/100,7％)高于下极被膜保留组(2/91,2.19％)(P＜0.05)。术后随访1年,两组均未出现局部感染及再发扁桃体肥大情况。结论 扁桃体下极被膜保留的扁桃体切除术是儿童OSA的一种安全可行的手术方式,可以有效降低术后出血风险及术后疼痛。     

Child behavior and quality of life before and after tonsillotomy versus tonsillectomy

Objectives

Compare two techniques for pediatric tonsil surgery with respect to postoperative pain and morbidity and changes in sleep behavior, health related quality of life (HRQL) and benefits due to surgery.

Methods

67 children (4.5-5.5 years) with tonsillar hypertrophy and obstructive sleep-disordered breathing with or without recurrent tonsillitis were randomized to either regular tonsillectomy (TE) (n = 32) or intracapsular tonsillectomy/tonsillotomy (TT) (n = 35) with Radiofrequency surgical technique (ellman Int.). Before TT/TE, the parents completed a validated Quality of Life survey of pediatric obstructive sleep apnea, the OSA-18 (Obstructive Sleep Apnea-18) and a standardized assessment of their children's behavior with the Child Behavior Checklist (CBCL). Six months after surgery, the parents repeated these measurements, and assessed the health related benefits of the surgery using the Glasgow Children's Benefit Inventory (GCBI).

Results

In the TT group, the children recorded less pain from the first day after surgery onwards, used fewer doses of painkillers and were pain-free 3 days earlier than the children in the TE group. Six months after surgery, there were no significant difference between TT and TE with regard to snoring and ENT-infections.The differences in the total scores and in all the individual domains between the initial OSA-18 and post-surgery scores were all significant (P < 0.0001). The improvement in the total problem score measured with CBCL was also significant (P < 0.01) and there was no difference between the TT and TE children. The improvements in all subscores of the GCBI indicated a significant health benefit of both TT and TE.

Conclusions

TT with RF-surgery causes less pain and postoperative morbidity than regular TE and has an equal effect on snoring and recurrent infections.Pre-school children with tonsillar hypertrophy and obstructive sleep-disordered breathing all show an impact on HRQL and behavior before surgery and improve dramatically just as much after TT as after TE. Therefore TT would be considered for treatment of small children.     

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.     

局部注射布比卡因或利多卡因对全身麻醉下儿童鼾症术后疼痛的影响

目的：比较局部注射布比卡因或利多卡因对全身麻醉下儿童鼾症术后疼痛的影响。方法：选取60例儿童鼾症患者分为3组,组1注射0．9％NaCl（生理盐水组）;组2注射0．25％布比卡因（布比卡因组）;组3注射2％利多卡因（利多卡因组）。采用面部表情模拟评分（McGrath’s facescale）记录术后2、6、12、18h和术后1、2、3、4、5、6、7d疼痛强度。结果：术后2、6h,3组疼痛值相似,差异无统计学意义（P〉O．05）;术后12h,布比卡因组疼痛值低于生理盐水组,有显著性差异（P（0．05）;术后18～24h直至术后7d,布比卡因组和利多卡因组疼痛值显著低于生理盐水组,有显著性差异（P（0．05）,但布比卡因组和利多卡因组比较无显著性差异（P2〉0．05）。生理盐水组的疼痛高峰在术后18h,布比卡因组和利多卡因组疼痛高峰在术后第2h且随着时间延长呈下降趋蛰．结诊．屠部沣茸寸布比卡因或利多卡因可有效减轻儿童鼾症术后疼痛．两者无显著件羊异．     

等离子扁桃体切除术与单极电刀扁桃体切除术的Meta分析

目的通过Meta分析的方法对等离子与单极电刀扁桃体切除术的效率、疗效及安全性进行比较,为临床治疗选择提供依据。方法电子检索Pubmed、Embase、Cochrane Library、维普、清华同方、万方、中国生物医学等数据库,获取等离子扁桃体切除术与单极电刀扁桃体切除术前瞻性随机对照研究的相关资料。用RevMan5．2统计软件对两种术式的术后出血、术后疼痛、手术时间、术中出血、术后恢复等指标进行分析比较,并进行系统评价及Meta分析。结果共有10篇文献（合计病例716例）纳入本研究。合并统计结果表明,两种术式的术后出血率[OR=1．02,95％C1（0．51,2．03）]、术后疼痛[SMD=-0．55,95％CI（-1．19,0．08）]、手术时间[SMD=0．60,95％C1（-0．08,1．28）]及术中出血量[SMD=0．34,95％c,（-0．02,0．69）]比较,差异均无统计学意义。术后活动恢复两者相当,等离子组患者能更快恢复正常饮食。结论相对单极电刀扁桃体切除术,等离子扁桃体切除术后饮食恢复较快;在术后出血、术后疼痛、手术时间、术中出血及术后活动恢复等方面无显著优势。