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.     

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.     

Ketamine peritonsillar infiltration during tonsillectomy in pediatric patients: An updated meta-analysis

Objectives

Peri-operative ketamine peritonsillar infiltration in children can reduce the incidence of postoperative nausea and vomiting (PONV), but its postoperative analgesic time is short. A previous meta-analysis in 2011 was inconclusive due to insufficient data. Consequently, we updated the meta-analysis to verify the role of ketamine peritonsillar infiltration for tonsillectomy in pediatric patients.

Methods

Ten randomized controlled trials with a total of 522 cases were included. Pain intensity was measured by standard modified CHEOPS score.

Results

The pain scores of ketamine group at 30 min and 60 min were significantly lower than placebo group after surgery [weighted mean difference (WMD) −1.20, 95% CI −2.20 to −0.19, P = 0.02; WMD −1.71, 95% CI −2.12 to −0.22, P = 0.02]. Analgesic requirement in ketamine group were less than placebo group [risk ratio (RR) 0.51, 95% CI 0.26–0.97; P = 0.04]. Moreover, the incidence of PONV was lower in ketamine group. (RR 0.73, 95% CI 0.54–0.97; P = 0.03). However, there were no differences between these two groups in operation time, anesthesia time, first analgesic time and pain score at 120 min.

Conclusions

Compared to placebo, ketamine peritonsillar infiltration can relieve postoperative pain within one hour but not at 120 min and reduces analgesic requirement and incidence of PONV. Moreover, there was no difference in the first analgesic time.     

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。     

Pharmacologic management of post-tonsillectomy pain in children

Tonsillectomy is a very common procedure in children, often performed on an outpatient basis. Severe postoperative pain is common, and can be prolonged. Despite a large number of available analgesic medications, often employed in combination, achieving adequate pain control remains a persistent challenge. Research suggests a tendency among caregivers to undertreat pain, and a need for detailed care instructions and education to ensure adequate pain management. Furthermore, ongoing questions regarding the safety and efficacy of the most commonly used medications have led to wide variance in practice patterns and continuous reassessment through research that yields sometimes conflicting results. This review summarizes the current state of the literature and presents a management approach which attempts to maximize pain control while minimizing potential harm with combinations of medications and modification based on patient-specific factors.     

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.     

Topical bupivacaine compared to lidocaine with epinephrine for post-tonsillectomy pain relief in children: a randomized controlled study

Objective

To compare the topical administration of bupivacaine hydrochloride, lidocaine hydrochloride with epinephrine and saline in alleviating post tonsillectomy pain.

Study design

A double-blind prospective randomized controlled clinical study.

Methods

Between November 2008 and March 2009, 60 patients (32 males and 28 females) between ages of 1.5 and 15 years were recruited into the study. After informed consent was obtained from the parents, patients, admitted for tonsillectomy, were randomized into three groups using sealed envelops. Group 1 (20 patients, mean age 5.2 ± 1.7) received topical lidocaine hydrochloride (20 mg/ml) with 0.00125% epinephrine. Group 2 (20 patients, mean age 6 ± 3.7) received topical 0.5% bupivacaine hydrochloride and group 3 (20 patients, mean age 6.7 ± 3.6) received topical saline.

Results

The post-operative pain scores at 1 h were similar among the groups (p = 0.29). Pain scores in bupivacaine hydrochloride group were significantly lesser than the saline group at 5th, 13th, 17th and 21st hours, until the sixth day (p < 0.017). Moreover, pain scores of bupivacaine hydrochloride group were superior to lidocaine hydrochloride group starting at 17 h, until fourth day (p < 0.017). Pain scores of lidocaine hydrochloride group were lesser than saline group in the first and fifth days (p < 0.017), whereas, there was no significant difference at other times.

Conclusion

Topical administration of bupivacaine hydrochloride proved to provide more efficient pain control than both saline and lidocaine without any drug related complication.     

The effects of levobupivacaine versus levobupivacaine plus magnesium infiltration on postoperative analgesia and laryngospasm in pediatric tonsillectomy patients

BACKGROUND: The aim of this study was to evaluate whether the addition of magnesium to levobupivacaine will decrease the postoperative analgesic requirement or not, and to investigate the possible preventive effects on laryngospasm. METHODS: Seventy-five children undergoing elective tonsillectomy and/or adenoidectomy surgery. The drug was prepared as only NaCl 0.9% for the first group (Group S, n=25), levobupivacaine 0.25% for the second group (Group L, n=25), and levobupivacaine 0.25% plus magnesium sulphate 2mg/kg for the third group (Group M, n=25). Pain was recorded at 15th minute, 1st, 4th, 8th, 16th, and 24th hour postoperatively. Pain was evaluated using a modified Children's Hospital of Eastern Ontario pain scale (mCHEOPS). Incidence of postoperative nausea and vomiting (PONV) was assessed at various time intervals (0-2, 2-6, 6-24h) by numeric rank score. Patients were followed for laryngospasm for 1h in recovery room after extubation. Other complications appeared within 24h postoperatively were recorded. RESULTS: All postoperative CHEOPS values were lower than control in both groups. Analgesic requirement was decreased significantly in both groups in comparison with control patients, but this requirement was significantly lower in Group M (p<0.05). Although laryngospasm was not observed in Group M, the difference between groups was not statistically significant. PONV was similar in both groups. CONCLUSIONS: Levobupivacaine and Levobupivacaine plus magnesium infiltration decrease the post-tonsillectomy analgesic requirement. Insignificant preventive effect of low doses of magnesium infiltration on laryngospasm observed in this study needs to be clarified by larger series.     

The effects of levobupivacaine infiltration on post-tonsillectomy pain relief in adults: a single-blinded, randomized, and controlled clinical study

The aim of this prospective single-blinded and controlled study is to evaluate the efficacy of levobupivacaine infiltration on post-tonsillectomy pain relief in adults. The study was conducted with 40 adult patients who underwent tonsillectomy. These patients were randomized in either study group (SG) who received levobupivacaine infiltration to peritonsillary fossae prior to surgery or control group (CG) with no medication. After surgery, all the patients were queried for pain scores by visual analog scale. In addition, the volume of intraoperative bleeding, the duration of operation, the severity of postoperative complications, and the amount of analgesic requirement were the other outcome measures of this study. There were significant differences between groups regarding pain scores for the first 24 h in favor of SG. The analgesic requirement was also significantly lower in SG (p = 0.009). Although there was a sustained decrement at pain score during first 24 h for SG, however, the change from baseline score (immediate score) for each time interval revealed no significance compared to CG. In addition, the duration of operation and the volume of intraoperative bleeding were similar (p = 0.64 and p = 0.165). In conclusion, preincisional infiltration of levobupivacaine is a safe and reliable method for post-tonsillectomy pain reduction in adults. However, more in-depth, double-blinded and placebo controlled studies are required to elucidate its long term benefits.     

Bupivacaine versus normal saline for relief of post-adenotonsillectomy pain in children: A meta-analysis

Objective

A meta-analysis was performed to explore the role of peri-operative bupivacaine infiltration in the relief of pain in adenotonsillectomy.

Methods

Data from Medline, EMBase, Springer and the Cochrane Collaboration database were searched. Reference lists from identified publications were scanned. RevMan 5.0 software was used for statistical analysis.

Results

7 random controlled tests (a total of 286 cases) were included. Pain intensity was evaluated by VAS score or Cheops score. The pain of group bupivacaine (Group B) was less severe than group placebo (Group P). Analgesic requirement of Group B was less than Group P. Nevertheless the difference of complication between bupivacaine and placebo had no statistical difference.

Conclusion

Bupivacaine infiltration is a safe and effective method for relief of pediatric post-adenotonsillectomy pain.     

Topical bupivacaine compared to bupivacaine infiltration for post-tonsillectomy pain relief in children: a prospective randomized controlled clinical study

The objective of this study is to compare the topical administration of bupivacaine hydrochloride, saline and bupivacaine hydrochloride infiltration on post-tonsillectomy pain in children. Sixty children undergoing tonsillectomy were enrolled in the study. Patients were randomized into three groups using sealed envelopes. Group 1 (n = 20) received topical 0.5 % bupivacaine hydrochloride, group 2 (n = 20) received topical 0.9 % NaCl (saline), and group 3 (n = 20) received 0.5 % bupivacaine hydrochloride infiltrated around each tonsil. Pain was evaluated using McGrath’s face scale. Pain scores in topical bupivacaine hydrochloride group was significantly lesser than the topical saline group at 5th, 13th, 17th and 21st hours, until the 6th day (p < 0.017). Moreover, pain scores of topical bupivacaine hydrochloride group was superior to bupivacaine hydrochloride infiltration group at 5th, 13th, 17th hours and 2nd, 3rd, 4th and 5th day (p < 0.017). There were significantly lesser morbidities in topical bupivacaine hydrochloride than saline group in 1st and 4th day (p < 0.017). Topical administration of bupivacaine hydrochloride proved to provide more efficient pain control than bupivacaine hydrochloride infiltration.     

Preemptive peritonsillar infiltration with lidocaine for relief of bipolar adult post-tonsillectomy pain: a randomized, double-blinded clinical study

There are discordant results in the studies of the peritonsillar infiltration in adults undergoing the tonsillectomy. The study is to compare the effect of the preemptive peritonsillar infiltration with lidocaine in bipolar tonsillectomy in adult. 172 adult patients were randomly located into five groups before tonsillectomy: group 0: without the peritonsillar infiltration, group 1: for 3 ml normal saline with 1:200,000 epinephrine per tonsil, group 2: for 3 ml 1 %lidocaine with 1:200,000 epinephrine per tonsil, group 3: for 8 ml normal saline with 1:200,000 epinephrine per tonsil, group 4: for 8 ml lidocaine with 1:200,000 epinephrine per tonsil. The post-operative pain in the following 7 days was assessed by visual analog scale. Operation time and post-operative bleeding were also recorded. No significant differences were found between operative times, post-tonsillectomy hemorrhage between the five groups. The differences between pain scores of the group 0, group 1 and group 2 were not statistically significant (P > 0.05). The differences between pain scores of group 3, group 4 against group 0, group 1, group 2 were statistically significant (P < 0.05). We found the volume of peritonsillar infiltration might contribute to the relief of pain of the bipolar post-tonsillectomy.     

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.     

Double‐blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain

Double‐blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain This double‐blind randomized controlled trial of coblation tonsillotomy versus coblation tonsillectomy uses visual analogue scoring to compare the pain experienced in the 24h postoperative period. No statistically significant difference in pain is demonstrated in the group of 14 patients studied. Tonsillectomy is recommended over tonsillotomy.     

Acupuncture instead of codeine for tonsillectomy pain in children

Objectives

Severe throat pain can result from tonsillectomy and last up to 10 days in children. Codeine elixir has long been used for pain relief, but has recently been banned by the Food and Drug Administration due to a recently recognized risk of death. We explored acupuncture as an alternative means of pain relief for children and adolescents after tonsillectomy.

Methods

This was a retrospective review of children and adolescents who underwent tonsillectomy over a three-month period. No narcotics were prescribed after surgery. Patients who wanted help with pain relief were offered acupuncture. Perceived pain level was assessed before and after the acupuncture treatment. Following the 10-day recovery for tonsillectomy, patients or their parents were queried as to how long the pain relief from acupuncture intervention was perceived to last.

Results

56 children and adolescents underwent tonsillectomy in the three-month window selected for the retrospective review. 31 of these patients (ranging from 2 to 17 years in age) received an acupuncture intervention for postoperative pain. The mean reported pain level before acupuncture was 5.52 (SD = 2.28) out of 10. This fell to 1.92 (SD = 2.43) after acupuncture. Statistical analysis supported the general conclusion that pain reports decline after acupuncture in the sampled population. However, the limitations of the methodology and the sample suggest that this generalization should be treated as preliminary. 17 patients or their parents provided a post-recovery report for how long they believed the acupuncture intervention lasted. The mean duration of perceived acupuncture benefit was 61.24 h, though the standard deviation was large (64.58 h) with about 30% of patients reporting less than three hours of benefit and about 30% reporting more than 60 h. No adverse effects were observed as a result of acupuncture treatments.

Conclusions

The data tentatively suggest that acupuncture decreases perceived pain in children and adolescents after tonsillectomy. These data – combined with the cost effectiveness, safety and ease of administering acupuncture – suggest that further studies exploring the effectiveness of acupuncture in juveniles after tonsillectomy are merited.     

The use of dexamethasone to reduce pain after tonsillectomy in adults: a double-blind prospective randomized trial

OBJECTIVES/HYPOTHESIS: To determine the effectiveness of dexamethasone to reduce pain after tonsillectomy in adults by at least 13 mm on the visual analogue scale. The secondary objective was to reduce the use of narcotics by at least 20%. STUDY DESIGN: This multicentric study is a prospective double-blind randomized controlled trial. METHODS: A total of 102 patients were enrolled and received a 4-day trial either of dexamethasone in decreasing doses or placebo. The patients were asked to note the level of pain on the visual analogue scale daily for 7 days. They also had to record their consumption of analgesic and any eventual side effects. RESULTS: There were no statistically or clinically significant differences between the two groups for the level of pain noted on the visual analogue scale for the first 4 and 7 days. There were no statistical differences for the consumption of hydromorphone between the two groups. CONCLUSION: We cannot recommend the use of dexamethasone on a routine basis following tonsillectomy in adults for the reduction of pain or narcotics consumption.     

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.     

A clinical prospective study of peritonsillar abscess in children

Distinguishing peritonsillar abscess from cellulitis is an important clinical problem, particularly in children, who may require a general anesthetic for drainage of these abscesses. In order to identify those clinical factors most significant for peritonsillar abscess, we did a prospective study of 21 patients who presented with sore throat, fever, trismus, and tonsillar bulge; all symptoms that are consistent with the diagnosis of peritonsillar abscess. On admission, the following parameters were recorded: patient age, duration of sore throat, fever, white blood cell count, drooling, the degree of trismus (measured exactly as incisor-incisor distance), the degree of pharyngotonsillar bulge, and change in voice. After 24 to 48 hours of parenteral antibiotics, 12 patients (57%) had improved sufficiently and were continued on antibiotics until resolution (cellulitis group). Nine patients (43%) had no improvement and underwent surgery for drainage of the peritonsillar abscess (abscess group). At the end of the 18-month study period, the cellulitis and abscess groups were compared. On admission, no significant difference was found in age, duration of sore throat, fever, or white blood cell count. The pharyngotonsillar bulge was mild in 58% and moderate in 42% of the cellulitis group, while in the abscess group, the pharyngotonsillar bulge was mild in only 33% and moderate in 67%. After 24 to 48 hours of parenteral antibiotics, all patients in the cellulitis group had improvement of at least one symptom; whereas, all patients in the abscess group had no change or worsening of at least one symptom, including trismus, dysphagia, voice change, drooling, or pharyngotonsillar bulge. On admission, the precise measurement of trismus was not significantly different in the two groups (24.7 mm in cellulitis group vs. 22.5 mm in abscess group). However, after 24 hours of antibiotics, trismus averaged 7 mm more in the abscess group versus the cellulitis group (p less than 0.05).