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。     

Does preincisional injection of levobupivacaine with epinephrine have any benefits for children undergoing tonsillectomy? An intraindividual evaluation

Objective

To evaluate the effects of peritonsillar injection of levobupivacaine with epinephrine in children undergoing adenotonsillectomy, through an intraindividual study.

Patients and methods

20 children (age 6-13 years) undergoing elective tonsillectomy with or without adenoidectomy were enrolled in this prospective, randomized, intraindividual trial. After entubation and just prior to incision, 3 ml of 0.25% levobupivacaine with epinephrine was injected into one peritonsillar region while 0.9% saline was being used for the contralateral side. Amount of intraoperative blood loss, duration of tonsillectomy, postoperative pain, otalgia and hemorrhage were assessed for each side separately. Visual analog scale was used for postoperative pain assessment. Heart rate and mean arterial pressure during and after operation were also observed. The follow-up period after surgery was 10 days.

Results

Median visual analog scale values for the levobupivacaine with epinephrine injected side was significantly lower than the saline injected side, during the first postoperative 16 h (p < 0.05). There were also significant differences between the intraoperative blood losses of the two sides (p < 0.05). However; no significant differences were observed with respect to duration of surgery, postoperative otalgia and hemorrhage (p > 0.05).

Conclusion

Preincisional injection of levobupivacaine with epinephrine decreases early postoperative pain and intraoperative blood loss as well.     

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.     

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.     

Comparación de 2 protocolos analgésicos en el control del dolor postamigdalectomía en pacientes adultos ambulatorios

Introduction and objectivesTonsillectomy causes a moderate to severe postoperative pain, and its treatment is an unsolved problem.The objective of this study was to compare the effectiveness of 2 analgesic protocols and their related complications.MethodsTwo groups of adult patients submitted to ambulatory tonsillectomy were studied. In group 1, 52 patients received a combination of tramadol and NSAIDs postoperatively; in group 2, 60 patients were treated with prednisone and NSAIDs. Two surgical techniques were used: cold dissection or dissection with electrocautery. Pain was recorded on days 4, 7 and 15, using a numerical scale from 0 to 10.ResultsBoth groups showed similar pain at postoperative day 4. At day 7, pain was higher in group 2 (P=.049), while at day 15 both groups showed only some discomfort. Sickness and vomiting was more frequent in group 1, and haemorrhage and hospitalisation in group 2. Cold dissection patients showed lower levels of pain at days 4 and 7, independently of analgesic protocol, and had lower haemorrhage and emergency visit rates.ConclusionsThe efficacy of both protocols was similar in terms of control of pain, with the exception of day 7; however, the protocol with prednisone showed fewer secondary effects. Patients operated using cold dissection had less pain and fewer complications.     

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.     

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.     

儿童扁桃体、腺样体低温等离子切除术后出血的临床研究

目的 探讨应用低温等离子手术或者传统手术方式行儿童扁桃体、腺样体切除术在术后出血方面存在的差异。方法 回顾性分析1597例接受手术治疗的儿童慢性扁桃体炎、腺样体肥大的患者资料,行等离子射频辅助的扁桃体和(或)腺样体切除术者793例(等离子组),行传统扁桃体切除和(或)腺样体者804例(传统组)。比较两组原发性及继发性出血的发生率、出血程度和出血部位的差异。结果 等离子组发生术后出血25例(3.2％),传统组出血19例(2.4％),两组间差异无统计学意义(χ2=3．34,P>0．05);其中等离子组原发性出血9例(1.1％),继发性出血16例(2.0％);传统组原发性出血11例(1.4％),继发性出血8例(1．0％),两者比较差异有统计学意义(χ2=9．45,P<0．01)。两组术后的出血部位经卡方检验,出血程度经Wilcoxon秩和检验,P值均>0．05,差异均无统计学意义。结论 低温等离子辅助行儿童扁桃体、腺样体切除术,在术后出血的发生率、程度、部位三个方面相对于传统的手术方法治疗,二者差异无统计学意义。     

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.     

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。     

The effects of topical levobupivacaine on morbidity in pediatric tonsillectomy patients

Objective

To reduce the post-tonsillectomy morbidity by swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml).

Study design

A double-blind prospective randomized controlled clinical study.

Methods

In this randomized double-blind study in group I (30 children, mean age 7.5 ± 2.6) we tightly packed swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml) and in group II (21 children, mean age 7.9 ± 3.7) we used 5 ml saline swabs into each of the two tonsillar fossae after tonsillectomy for 5 min. We used McGrath's face scale to compare the two groups in respect of pain control.

Results

There was statistically significant pain relieving effect in the levobupivacaine group in the first 24 h (p < 0.05). But after 24 h pain relieving effect of levobupivacaine was not significant (p > 0.05). We did not see any serious complications for both groups. Postoperative morbidity mean results (nausea, vomiting, fever, bleeding, halitosis and ear pain) were not statistically different between the two groups (p > 0.05).

Conclusion

Topical levobupivacaine seems to be a safe and easy medication for postoperative pain control in pediatric tonsillectomy patients.     

Difference of delayed post-tonsillectomy bleeding between children and adults

Objective

To analyze the characteristics of post-tonsillectomy bleeding and its management comparing with adults.

Methods

A retrospective chart review of 1489 patients who underwent tonsillectomy in our institution (June 2003–June 2006).

Results

Post-tonsillectomy bleeding rate was 3.1%, 2.5% and 10.8% in younger children (age ≤ 11 years), older children (12 ≤ age ≤ 15 years) and adults (age > 15 years), respectively. Although adults showed an unimodal peak time for onset of post-tonsillectomy bleeding, children showed a bimodal peak time. In the younger child group, all of the 28 bleeders had spontaneous hemostasis. However, in the older child group, there was no spontaneous hemostasis. Bleeding was controlled under local anesthesia in 3 patients and 2 patients required general anesthesia for bleeding control. In the adult group, spontaneous cessation of bleeding occurred in 25 patients (60.9%) and hemostasis under local or general anesthesia was performed in 16 (39.1%) patients.

Conclusions

Post-tonsillectomy bleeding occurred more frequently in adults than in children. Spontaneous hemostasis was more prevalent in children than in adults. Post-tonsillectomy bleeding in the younger child group was controlled with close observation alone.     

Analgesia after tonsillectomy with controlled intravenous morphine — overdue or exaggerated?

ObjectiveTo assess the value of a morphine Patient Controlled Intravenous Analgesia (PCIA) after Tonsillectomies (TE).Methods30 adult patients were treated with oral analgesics (protocol group) and compared to 30 patients treated with a morphine PCIA for the first 3 Postoperative Days (PODs) after TE. Average and maximum pain severities (Numeric Rating Scale – NRS: 0–10) on PODs 1–3, analgesic score, quality of life, patient satisfaction and side effects were defined as outcome measures.ResultsAverage pain severities of the protocol and the PCIA group were of similar magnitude (NRS) (POD1: 4.48 vs. 4.71 [p = 0.68], POD2: 4.75 vs. 4.22 [p = 0.32] and POD3: 4.44 vs. 4.25 [p = 0.71]). Maximum pain intensities on POD1 (p = 0.92), POD2 (p = 0.51) and POD3 (p = 0.36) were also comparable between both groups. Patients with a PCIA consumed significantly more opioids (p = 0.001) without significant more side-effects.ConclusionThe PCIA did not provide a superior pain control compared to oral analgesics. In view of the considerable effort and the high opioid consumption, it cannot be recommended as a standardized application for pain control after TE.     

Determination of optimum dosage of intraoperative single dose dexamethasone in pediatric tonsillectomy and adenotonsillectomy

Objective

Our objective is to determine the optimum dosage of intraoperative single dose dexamethasone and its effect upon postoperative morbidity in pediatric tonsillectomy and adenotonsillectomy patients.

Study design and methods

Totally 150 pediatric patients whom underwent adenotonsillectomy or tonsillectomy surgery are offered to participate in this study at otorhinolaryngology clinic between 2002 and 2003. 150 patients are divided into three randomized groups, each composed of fifty patients. Anesthesia protocol is standardized in each group and 0.2 mg/kg intraoperative dexamethasone is given to first group, 0.7 mg/kg (maximum dose 25 mg) intraoperative dexamethasone is given to second group and third group is accepted as control group without giving any intravenous dexamethasone. Each group is compared for postoperative nausea, vomiting and tolerability to take oral foods within first 24 h with the same questionnaire.

Results

There is significantly higher ratio of postoperative nausea and vomiting within first 24 h in group III (80%) when compared with group I (8%) (p: 0.001; p < 0.01) and group II (4%) (p: 0.001; p < 0.01). Also there is significantly higher ratio of patient's tolerability to take oral semisolid/solid foods within postoperative first 24 h in group II (94%) when compared with group I (58%) (p: 0.001; p < 0.01) and group III (12%) (p: 0.001; p < 0.01). We didn’t encounter any side effect of dexamethasone in group I and II.

Conclusions

We thought that 0.7 mg/kg dosage of IV dexamethasone is much a preferable choice depending of its effectiveness on decreasing postoperative morbidity rather than 0.2 mg/kg dosage and beside to this advantage we didn’t encounter any side effects.     

低温等离子联合血管缝扎在扁桃体切除中的临床应用

扁桃体切除术是耳鼻咽喉科常见手术之一,切除方法多种,但“作易精难”[1],存在术后出血多,术后疼痛剧烈及伤口愈合差等诸多并发症。因此临床上一直在探讨一种术式能够减轻患者的疼痛,减少术中及术后出血,使创面尽早恢复。低温等离子技术是近几年发展的一项新技术,已广泛应用于扁桃体的切除,与传统的手术方法相比,低温等离子射频消融术具有微创、出血少、疼痛程度低、康复周期短等优点[2],但国内文献报告扁桃体术后出血发生率仍为2%～8%,因此借助低温等离子技术,寻求一种既微创又可以减少并发症的术式值得临床探讨。本文回顾性分析比较采用低温等离子联合血管缝扎切除扁桃体与单纯低温等离子切除扁桃体病例,观察患儿术后出血情况,以期为临床选择更优化的手术方式提供依据。