Subtotal bipolar tonsillectomy does not decrease postoperative pain compared to total monopolar tonsillectomy

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Summary

Objective

To determine whether a subtotal bovie tonsillectomy decreases postoperative pain following adenotonsillectomy.

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, undergoing adenotonsillectomy. Patients were randomized to receive either a subtotal or total removal of the tonsils utilizing an electrocautery technique. The main outcome measures included a visual analog scale (VAS) at rest and while eating, time to take 100 cm3 of fluid, throat, neck, and ear pain, quantity of liquids, activity level and incidence of emesis and retching.

Results

A repeated measures analysis using a repeated measures ANOVA failed to demonstrate a statistically significant impact with either treatment for VAS at rest or while eating (p = 0.52 and 0.48, respectively). A repeated measures analysis did not show either procedure significantly affecting throat, neck or ear pain, or liquid quantity. Time to take 100 cm3 liquids and the incidence of emesis or retching were found not to be statistically significantly different between the treatment groups.

Conclusion

Subtotal tonsillectomy via an electrocautery technique does not reduce postoperative pain or improve outcome parameters. Subtotal tonsillectomy with this technique is not recommended for this patient population.

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)

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