International Journal of Pediatric Otorhinolaryngology
Subtotal bipolar tonsillectomy does not decrease postoperative pain compared to total monopolar tonsillectomy
Introduction
Tonsillectomy is the second most common head and neck operation performed on children under the age of 15 [1]. Pain is one of the most common complaints after tonsillectomy, and it can be severe enough to prevent maintenance of adequate hydration. Warnock and Lander reviewed the outcomes of 129 children following adenotonsillectomy and noted considerable pain that lasted more than 7 days [2]. This intense pain may result in dehydration and account for up to almost 1% of all post-tonsillectomy patients requiring readmission [3].
Multiple techniques have been advocated for reducing postoperative adenotonsillectomy pain. One technique called a subtotal tonsillectomy involves leaving the capsule of the tonsil and an attached rim of residual tonsil tissue intact [4]. Proponents of this technique claim that the postoperative pain is reduced by preventing the surrounding musculature from being exposed. Another technique called coblation uses an electrical current that is run through a small drop of water to create a “plasma layer” that ablates tissue [5]. This plasma layer ablates the tonsillar tissue at a lower temperature than conventional electrocautery and may reduce pain by minimizing thermal injury. Lastly, subtotal tonsillectomy utilizing a radiofrequency bipolar “scissors” has been investigated for decreasing postoperative pain [6]. There has been speculation that its efficacy is related to both a decrease in thermal injury from the bipolar effect and by leaving a thin rim of tonsillar tissue (and the tonsillar capsule) intact.
The current study aims to address whether a subtotal bipolar adenotonsillectomy will improve postoperative outcomes when compared to a total tonsillectomy. We hypothesize that a bipolar subtotal tonsillectomy will provide reduced postoperative pain based on a visual analog scale. Such a positive result would help the thousands of children who undergo this procedure annually.
Section snippets
Methods
A prospective, randomized, double-blinded clinical trial was undertaken at a university pediatric children's hospital and included 39 otherwise healthy children, aged 2–12 years, who were undergoing adenotonsillectomy for airway obstruction or difficulty breathing. Patients with diabetes, cardiac conduction abnormalities, electrolyte abnormalities, liver or kidney insufficiency, hypersensitivity to acetaminophen or hydrocodone, history of chronic pain, pregnancy, were excluded from enrolling in
Results
Forty children were enrolled in the study with 19 undergoing subtotal tonsillectomy and 21 undergoing total removal of the tonsils. One patient in the bipolar cautery group was lost to follow-up and was not included in the subsequent assessment. The patients were comparable between the two groups with respect to age, weight, sex, duration of surgery, estimated blood loss, and tonsil and adenoid size (Table 1).
Pain measurements based on a visual analog scale (VAS) at rest and while eating failed
Discussion
Tonsillectomy is one of the most common surgical procedures performed in children. Recurrent tonsil infections or obstructed breathing are the most common reasons tonsillectomy is usually performed. The tonsils are bilateral lymphoid structures located in the oropharynx. This tissue is located in a fossa bounded by structures on three sides. The anterior and posterior tonsillar pillars are provided anatomic definition by the palatoglossus or paltopharyngus muscles, respectively. The lateral, or
Acknowledgements
The authors wish to thank all the families who participated in this study.
References (11)
- et al.
Pain progression, intensity and outcomes following tonsillectomy
Pain
(1998) - et al.
Bipolar Scissors versus cold dissection for pediatric tonsillectomy—a prospective, randomized pilot study
Int. J. Pediatr. Otorhinolaryngol.
(2002) Randomized controlled trial of coblation versus electrocautery tonsillectomy
Otolaryngol. Head Neck Surg.
(2005)- Vital Health Statistics. CDC,...
- et al.
Complications of outpatient tonsillectomy and adenoidectomy: a review of 3340 cases
Ear Nose Throat J.
(1990)
Cited by (16)
Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing
2017, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :19 studies utilised a pain scale, such as the Wong-Baker FACES scoring system, whereas 21 assessed pain via a days-until system (eg. days until pain or analgesia free). Four of the 19 studies assessing pain scales found no difference between tonsillotomy and tonsillectomy [21–24]. The remainder reported less pain amongst tonsillotomy children, with the greatest difference in pain scores at post-operative day 3–5.
Adherence of randomized trials within children's surgical specialties published during 2000 to 2009 to standard reporting guidelines
2013, Journal of the American College of SurgeonsAre randomised controlled trials involving adenotonsillectomy well reported?
2011, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :The abstracts were screened and 93 trials were excluded. 25 papers were included in this study [6–30]. A summary of the reporting from each trial for each item of the CONSORT checklist is presented in Table 1.
Making sense out of the tonsillectomy literature
2009, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :The methodology for adenoidectomy was described or referenced in 36 (63%) of the 57 studies in which adenoidectomy was performed in some or all of the subjects [4,13,14,21–26,28,29,31–34,37–57]. Seventeen (30%) of the 57 studies in which adenoidectomy was performed separated out patients who underwent concurrent adenoidectomy and also described or referenced the adenoidectomy technique [4,14,24–26,28,29,31–34,37–42]. Five (6%) studies excluded patients if they had already had adenoidectomy [7,58–61] and seven (8%) of the studies performed adenoidectomies on all of the children [13,23,43,47,50,53,54].
An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea
2023, Journal of Maxillofacial and Oral SurgeryTonsillectomy versus tonsillotomy for obstructive sleep-disordered breathing in children
2020, Cochrane Database of Systematic Reviews