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     

Effect of post-operative oral steroids on bleeding rate after pediatric tonsillectomy

PurposeIn 2013, the FDA placed a black box warning on the usage of opioid pain medications in the post-operative setting after pediatric adenotonsillectomy. Since then, alternative pain management regimens have been employed. Some have advocated for post-operative oral steroids, in part due to the effectiveness of intraoperative intravenous steroids in reducing post-operative pain and nausea. The evidence regarding the efficacy and safety of post-operative oral steroids is not as clear. The purpose of this study was to examine whether post-tonsillectomy hemorrhage rates in pediatric patients were affected by post-operative oral steroid usage.Materials and methodsCase-control retrospective chart review using a deidentified data set of patients undergoing tonsillectomy with or without adenoidectomy at a single academic medical center between June 2012 and November 2015.ResultsA total of 1416 patients were included in the study, with 704 in the no post-operative oral steroids group and 712 in the group who did receive post-operative oral steroids. The rate of post-tonsillectomy hemorrhage in the post-operative oral steroid group was 3.1 % compared to 1.8 % in the group who did not receive post-operative oral steroids, however, this was not a statistically significant difference (P = .132).ConclusionsOur study suggests that post-operative oral steroids are safe and do not increase the risk of post-operative hemorrhage after pediatric tonsillectomy.     

Use of Floseal and effects on wound healing and pain in adults undergoing tonsillectomy: randomised comparison versus electrocautery

The objective of this study was to evaluate the effect of FloSeal^? (FS, Baxter Healthcare, Deerfield, IL, USA) as a haemostatic matrix in comparison to bipolar electrocautery (EC) after tonsillectomy. Eligible patients were adults undergoing cold-knife tonsillectomy because of recurrent tonsillitis, tonsillar hypertrophy, or peritonsillar abscess (more than 3?months previously). Patients were randomly allocated, on a single-blind basis, to either FS or EC for haemostasis during tonsillectomy. Five experienced surgeons judged the handling of FS application using a five-point scale (very good, good, fair, poor, very poor). Postoperative pain scores were evaluated with a visual analogue scale for 20?days, and the duration under pain medication together with the consumption of pain medication was compared. Wound healing was documented on Days 1–5, 10, and 20. A total of 176 patients were enrolled. Overall, 76/77 (98.7%) of surgeon evaluations of FS handling were judged at least “good”. FS-treated patients showed significantly improved wound healing (less thickness of wound plaques) throughout the postoperative observation period, a trend for less postoperative pain (cumulative pain intensity score; P?=?0.074), and a significantly shorter duration of pain-medication use (9.5 vs. 11.6?days; P?=?0.014) as well as reduced pain-medication consumption/demand (P?=?0.032). No difference in the rate of postoperative haemorrhage was observed between the two treatment groups (4.9% for FS patients, 6.0% for EC patients, P?=?0.76). In conclusion, this study demonstrates the easy handling of FS application in tonsillectomy. Its use instead of EC after cold-steel tonsillectomy shows beneficial effects on mucosal recovery, as assessed by a decrease in the thickness of wound coating. Furthermore, FS is associated with a significantly shortened duration of pain-medication use and overall reduction in consumption/demand.     

The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy

OBJECTIVE: Postoperative morbidity in patients undergoing tonsillectomy with or without adenoidectomy includes inadequate oral intake, pain, nausea, vomiting and bleeding. The purpose of this study is to evaluate the effect of preoperative 0.5 mg/kg i.v. dexamethasone on postoperative early oral intake, pain, vomiting in patients undergoing adenotonsillectomy while performing standard anesthesia technique and sharp dissection tonsillectomy. METHODS: In this prospective, double-blinded, placebo-controlled study 62 children, aged 4-12 years, who underwent tonsillectomy with or without adenoidectomy were randomly assigned to receive single dose of 0.5 mg/kg i.v. dexamethasone preoperatively. Patients started to receive 100 ml of clear fluids 2 h postoperatively, then were offered every hour. When pain score was 3 or above, paracetamol was given for pain control. Tolerating 400 ml of clear fluids, no bleeding and no vomiting were accepted as discharge criteria. The discharge time was also recorded. The incidence of early vomiting, pain scores, amount of oral intake were recorded until the discharge time. RESULTS: Compared with placebo, the patients who received preoperative dexamethasone had significantly less pain score during the first 6 h postoperatively (p<0.05), adequate amount of oral intake time was shorter (p<0.05) and the discharge time was earlier (p<0.05). No difference was found in vomiting incidence in both groups. CONCLUSION: Preoperative dexamethasone use significantly reduces early posttonsillectomy pain, improves oral intake and facilitates meeting the discharge criteria while using standard anesthesia technique and sharp dissection tonsillectomy without any significant side effects.     

The effect of preoperative irradiation on wound healing after laryngectomy--literature review and own results

We reviewed 573 patients who underwent total laryngectomy between 1989-1999 in the Otolaryngological Clinic of CM UMK. Pharyngocutaneous fistulae occurred in 65 cases (11.3%). In 16 patients who were preoperatively irradiated, the fistulae occurred in 7 cases (43.7%). In the non-radiotherapy group of 557 persons, in 58 cases (10.4%) after total laryngectomy, the wound healing was disturbed and a pharyngocutaneous fistula was observed. The authors reviewed the Polish and the foreign literature concerning the influence of preoperative radiotherapy on wound healing after surgical treatment of larynx carcinomas.     

The effect of preoperative adriamycin and dihydroxyanthracenedione on wound healing

Preoperative adjuvant chemotherapy is being used with increasing frequency in advanced head and neck cancer; however, the effects of chemotherapy on wound healing have not been fully elucidated. To evaluate the effect of preoperative chemotherapy, experimental animals were given chemotherapeutic drugs, wounded, and the subequent wound breaking strength determined. Rats received a single dose of intravenous tumoricidal drugs (adriamycin or dihydroxyanthracenedione) either one week before or simultaneously with wounding. Wound breaking strength of treated animals and control animals receiving no chemotherapy was measured one and two weeks after wounding. All wounds, regardless of treatment, were stronger at two weeks than at one week after wounding. Wound breaking strength was reduced at both times when chemotherapy was administered one week before wounding. Wound breaking strength in animals that were simultaneously wounded and received chemotherapy was similar to controls. Both adriamycin and dihydroxyanthracenedione have a deleterious effect on one parameter of wound healing — wound breaking strength — when administered one week before wounding.     

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.     

Complex evaluation of pain after tonsillectomy

Conclusion. Postoperative odynophagia should be assessed by a variety of methods including visual analogue scale (VAS) pain scores (subjective), clinical data (objective qualitative) and surface electromyography (sEMG; objective quantitative). sEMG might be used for quantitative evaluation of odynophagia when aggravation or hysteria-conversion reaction is suspected. Tonsillectomy affects muscle activity significantly by involving additional muscles in deglutition. Objectives. Complex evaluation of post tonsillectomy odynophagia was used for objective assessment of complaints of operated patients. Patients and methods. Parameters evaluated for 50 randomly chosen operated adults included VAS pain score, clinical data, and the EMG data such as the timing, electric amplitude and graphic patterns of muscular activity during deglutition. We investigated masseter (MS), infrahyoid (INF) and submental-submandibular (SUB) muscles. The results were compared with a normative database. The patients were first tested 12 h after surgery and were monitored for 30 days. The sEMG data were compared with VAS pain score with regard to changes in clinical condition of the patients. Results. Signs of clinical recovery after tonsillectomy did not always correspond with the VAS pain score evolution. sEMG was more in concord with clinical recovery than VAS. Electric activity of MS and LSM was significantly higher among the patients in comparison with a normative database (p<0.005).     

Complex evaluation of pain after tonsillectomy

CONCLUSION: Postoperative odynophagia should be assessed by a variety of methods including visual analogue scale (VAS) pain scores (subjective), clinical data (objective qualitative) and surface electromyography (sEMG; objective quantitative). sEMG might be used for quantitative evaluation of odynophagia when aggravation or hysteria-conversion reaction is suspected. Tonsillectomy affects muscle activity significantly by involving additional muscles in deglutition. OBJECTIVES: Complex evaluation of post tonsillectomy odynophagia was used for objective assessment of complaints of operated patients. PATIENTS AND METHODS: Parameters evaluated for 50 randomly chosen operated adults included VAS pain score, clinical data, and the EMG data such as the timing, electric amplitude and graphic patterns of muscular activity during deglutition. We investigated masseter (MS), infrahyoid (INF) and submental-submandibular (SUB) muscles. The results were compared with a normative database. The patients were first tested 12 h after surgery and were monitored for 30 days. The sEMG data were compared with VAS pain score with regard to changes in clinical condition of the patients. RESULTS: Signs of clinical recovery after tonsillectomy did not always correspond with the VAS pain score evolution. sEMG was more in concord with clinical recovery than VAS. Electric activity of MS and LSM was significantly higher among the patients in comparison with a normative database (p<0.005).     

The effect of platelet-derived growth factor on tracheal wound healing

In order to evaluate a new method for the direct application of a polypeptide growth factor to injured tracheal epithelium and to determine the effect of topical platelet-derived growth factor (PDGF) on tracheal wound healing, a controlled animal study was designed using six adult beagle dogs. Four 2x1 cm mucosal defects were created in the tracheal lumen of each dog for a total of 24 experimental sites. Twelve wounds were treated with PDGF in a collagen-fibrin composite tissue adhesive (CTA) carrier. Eight sites received CTA alone and four were left untreated. Healing was assessed by endoscopic exam on post-operative days 4, 7, 10, 14, 17 and 21. The animals were sacrificed on day 21 and the tracheas were harvested for histological examination of the experimental sites and adjacent unwounded trachea. By 21 days, complete healing of all sites was observed endoscopically. Wounds treated with CTA or PDGF-CTA healed at a faster rate than control sites. The PDGF-CTA treated wounds demonstrated excessive granulation tissue formation. Histological examination demonstrated a higher percentage of wound coverage with ciliated epithelium most similar to normal trachea in the PDGF treated wounds. CTA is effective as a carrier for the direct delivery of a growth factor to injured tracheal epithelium. The application of CTA or PDGF-CTA results in a more rapid rate of tracheal wound healing as compared with control wounds. PDGF-CTA led to increased acute local inflammatory changes but was associated with a structurally more normal respiratory epithelium after healing. Physiological studies are necessary to determine the functional significance of these findings.     

Ropivacaine with or without clonidine improves pediatric tonsillectomy pain

OBJECTIVE: To determine if preemptive analgesia with ropivacaine hydrochloride with or without clonidine hydrochloride decreases pain and hastens recovery after tonsillectomy. DESIGN: Prospective, randomized, triple-blinded trial. SETTING: University referral center; pediatric ambulatory practice. PARTICIPANTS: Sixty-four children, aged 3 to 15 years, undergoing tonsillectomy. INTERVENTIONS: Patients received injections in the tonsillar fossae of isotonic sodium chloride, ropivacaine, or ropivacaine plus clonidine prior to tonsil excision. MAIN OUTCOME MEASURES: Visual analogue (pain) scale scores at rest and when drinking, opioid use, recovery time to normal activity, and incidence of symptoms such as otalgia. RESULTS: Pain was reduced on postoperative day 0 in the ropivacaine-treated and ropivacaine plus clonidine-treated groups as compared with the isotonic sodium chloride-treated group (P<.05). Pain was also decreased in the ropivacaine plus clonidine-treated group on postoperative days 3 and 5 (P<.05). Intravenous narcotic use was decreased on day 0 in the ropivacaine-treated and ropivacaine plus clonidine-treated groups (P<.05). Cumulative codeine use was similar at day 3 for all patients, but was decreased at day 5 in the ropivacaine plus clonidine-treated group (P<.05). The incidence of otalgia decreased from 89% (16/18) in the isotonic sodium chloride-treated group to 63% (12/19) in the ropivacaine-treated and 61%(11/18) in the ropivacaine plus clonidine-treated groups (P<.01). Recovery to normal activity was shortened from 8.1 +/- 1.6 days to 5.8 +/- 2.9 days (mean +/- SD) in the isotonic sodium chloride-treated and ropivacaine plus clonidine-treated groups, respectively (P =.03). CONCLUSION: Preincisional injection of ropivacaine with clonidine prior to tonsillectomy has a preemptive analgesic effect that outlasts the local anesthetic and decreases pain, opioid use, and the time to return to normal activity.     

Dexamethasone reduces pain after tonsillectomy in adults

The aim of this study was to assess the effect of a course of dexamethasone on postoperative pain and morbidity after adult tonsillectomy. We report the results of a double-blind, randomized, placebo-controlled trial of 200 adult patients undergoing elective tonsillectomy. Patients were randomized to three groups: one group received the non-steroidal anti-inflammatory drug piroxicam for 8 days postoperatively, one group received dexamethasone for the same period and the third group received both drugs. Patients recorded their pain scores and analgesic requirements daily for 10 days. Patients treated with a combination of piroxicam and dexamethasone recorded consistently lower pain scores than those treated with either drug alone. This difference was statistically significant (P < 0.05) on all days except the day of surgery and the second postoperative day. Patients treated with piroxicam alone had significantly higher analgesic requirements than in either of the other groups. Dexamethasone given in this regime reduces postoperative pain and analgesic requirements after adult tonsillectomy.     

冷、热止血法与扁桃体切除术后疼痛关系的比较研究

目的观察电凝器喷凝止血法（热止血法）和压迫缝扎止血法（冷止血法）与扁桃体切除术后疼痛的相关性。方法行扁桃体摘除术的慢性扁桃体炎患者100例，分为2组，术中分别采用冷止血法和热止血法进行创面止血。分别记录术中出血量，术后每天观察进食情况以记录正常进食时间；采用McGill疼痛量表法，于术后第3天进行疼痛评分并作组问比较分析。结果热止血法组病例的术中平均出血量及术后进食时间分别为10．26±0．69ml和H2．52±0．42d，而冷止血法组病例则分别为12．52±0．45ml及2．12±0．63d（P〈0．05）；比较术后疼痛持续时间，热止血法组病例有3个指标明显大于冷止血法组，仅1个指标明显短于后者（均P〈0．05），其余指标组间差异无统计学意义（P〉0．05）。结论热止血法手术操作较安全，术中出血量较少，但术后疼痛较明显。因而，应根据患者术中的具体情况灵活选择止血方法。     

Autologous fibrin sealant reduces pain after tonsillectomy

Objectives/Hypothesis Pain is a major cause of morbidity after tonsillectomy. Although various efforts have been made to reduce pain, the use of oral analgesics, which can have adverse side effects, remains the standard of care. It is hypothesized that fibrin sealant, used to achieve hemostasis and enhance healing in many surgical procedures, might help decrease pain after this operation. Study Design A prospective, randomized, blinded study was performed on 20 children aged 5 to 17 years who were undergoing tonsillectomy, to evaluate the efficacy of FIBRIN SEALANT in reducing postoperative pain. Methods All patients pre‐donated 40 mL of blood from which autologous concentrated fibrinogen was prepared by cryoprecipitation. In the fibrin sealant group, fibrinogen and topical bovine thrombin were sprayed onto the surgical site to form fibrin sealant at the conclusion of tonsillectomy. The 10 patients in the control group (C) received no fibrin sealant. Patients rated their level of pain immediately after surgery and at regular intervals for 3 days after surgery using the Wong‐Baker Faces Pain Rating Scale (1–6). Emesis, postoperative bleeding, medications, and adverse events were also evaluated. Results At 7:00 p.m. on postoperative day (POD) 0, the mean ± SD fibrin sealant group pain score (2.9 ± 0.41 units) was significantly lower than for the C group (4.1 ± 0.43 units;P ≤ .05). There was also a trend in favor of less pain in the fibrin sealant group at 7:00 p.m. on POD 1, with a mean of 3.5 ± 0.43 units versus 2.4 ± 0.48 units for C (P = .15). The odds of a patient in C experiencing emesis were 8.16 times higher, (P ≤ .05) than for patients in the fibrin sealant group. Conclusions Fibrin sealant significantly reduced pain the evening after pediatric tonsillectomy and also decreased the chance of e‐periencing emesis. Thus fibrin sealant may be clinically useful as an adjunct to tonsillectomy.     

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.