New parameters measured via preoperative tonsil photos to evaluate the post-tonsillectomy pain: an analysis assisted by machine learning.

Background: Postoperative pain is the most common complication after tonsillectomy. We aimed to explore new parameters related to post-tonsillectomy pain, as well as to construct and validate a model for the preoperative evaluation of patients' risk for postoperative pain. Methods: Data collected from patients who underwent tonsillectomy by the same surgeon at Beijing Chaoyang Hospital from January 2019 to May 2022 were analyzed. Preoperative tonsil images from all patients were taken, and the ratios of the distance between the upper pole of the tonsil and the base of the uvula (L1 for the left side and R1 for the right side) to the width of the uvula (U1) or the length of the uvula (U2) were measured. The following six ratios were calculated: L1/U1, R1/U1, LR1/U1 (the add of L1 and R1, and then divide U1), L1/U2, R1/U2, LR1/U2 (the add of L1 and R1, and then divide U2). The post-tonsillectomy pain was recorded. In addition, machine learning (ML) algorithm and feature importance analysis were used to evaluate the value of the parameters. Results: A total of 100 patients were involved and divided into the training set (60%) and the validation set (40%). All six parameters are negatively correlated with post-tonsillectomy pain. The accuracy, sensitivity, and specificity of the model were 75.0%, 72.7%, and 77.8%, respectively. LR1/U1 and LR1/U2 are the most valuable parameters to evaluate post-tonsillectomy pain. Conclusions: We have discovered new parameters that can be measured using preoperative tonsil images to evaluate post-tonsillectomy pain. ML models based on these parameters could predict whether these patients will have intolerable pain after tonsillectomy and manage it promptly.

Tonsillectomy Outcomes for Coblation Versus Bipolar Diathermy Techniques in Adult Patients: A Systematic Review and Meta-Analysis.

INTRODUCTION AND AIMS: There is no consensus on the optimal tonsillectomy technique in adult patients. The study aims to identify all studies comparing the outcomes of coblation versus bipolar diathermy in adult patients undergoing tonsillectomy. METHODS: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary outcomes were hemorrhage and postoperative pain. Secondary outcome measures included return to theatre, analgesia, intraoperative bleeding, diet, tonsillar healing, and operation time. Fixed-effects modeling was used for the analysis. RESULTS: Six studies were identified enrolling a total of 1824 patients. There were no significant differences in terms of reactionary hemorrhage (OR = 1.81, P = .51), delayed hemorrhage (OR = 0.72, P = .20), or postoperative pain (mean difference = -0.15, P = .45); however, there is a general trend favuring coblation. For secondary outcomes, no significant differences noted in terms of intraoperative bleeding, diet, and cases returning to theatre. Analgesia administration was either insignificant or higher in the coblation group. The coblation group had longer operation time and greater healing effect on tonsillar tissue. CONCLUSIONS: There were no significant differences in outcomes for coblation and bipolar diathermy for adult tonsillectomy patients in this systematic review and meta-analysis.

Comparing the efficacy of peritonsillar injection of bupivacaine and intravenous acetaminophen on post-tonsillectomy pain in children.

INTRODUCTION: In this study we aimed to compare the efficacy of peritonsillar injection of bupivacaine and intravenous acetaminophen on post-tonsillectomy pain in children. MATERIALS AND METHODS: In this randomized double-blind clinical trial study 60 children with ASA = I-II aged 5-12 years undergoing tonsillectomy were involved. The first group received bupivacaine at a dose of 0.1 mg/kg that was injected into the bed and the anterior crease of each tonsil. The second group was given intravenous acetaminophen at a dose of 12.5 mg/kg. The patient's pain score at 10, 30, 60 min after his/her admission to recovery room and 120, 240 and 360 min after the surgery was recorded using CHEOPS. Patient's sedation score, nausea or vomiting, the time of the first request for analgesia and the time of starting oral feeding were recorded and analyzed too. RESULTS: There was no significant differences in mean age (p value = 0.44), gender (p value = 0.79), weight (p value = 0.36), height (p value = 0.17), anesthesia duration (p.value = 0.85) and surgery duration (p.value = 0.73) between two groups. Postoperative pain was significantly less in the bupivacaine group at 240 and 360 min after the surgery. The mean sedation score was higher in the bupivacaine group but not significantly. There was no significant difference between groups regarding the nausea and vomiting, the first analgesics request time and the start time of oral feeding. CONCLUSION: According to the results of the present study, since administration of peritonsillar bupivacaine compared to acetaminophen had a better effect on managing postoperative pain and improving sedation and also since no complications were reported; therefore, peritonsillar infiltration with bupivacaine is suggested for pediatric tonsillectomy.

Comparison of the effect of peritonsillar infiltration of tramadol vs dexmedetomidine on post-tonsillectomy pain.

INTRODUCTION: This study aimed to comparing the effect of peritonsillar infiltration of tramadol and dexmedetomidine in relieving post-tonsillectomy pain. METHODS: In this randomized double blinded clinical trial study, 90 children 5-12 years old undergoing tonsillectomy, involved. Induction of anesthesia was done by fentanyl 1 µg/kg, sodium thiopental 5 mg/kg and atracurium 0.5 mg/kg and intubation was done after 3 min. Anesthesia maintained by nitrous oxide 60% and oxygen 40% with isoflurane (1.2%). Tramadol 2 mg/kg in group A, dexmedetomidine 1 µg/kg in group B, and normal saline in group c were injected into the bed and anterior tonsillar pillar and surgery has begun after 3 min of injection. Time of surgery, all hemodynamic variables, pain intensity and degree of sedation were recorded and evaluated. RESULTS: The results showed that duration of the surgery (p value = 0.28) and duration of anesthesia (p value = 0.43) were not significantly different between the groups but pain score was significantly lower in dexmedetomidine group in comparison to tramadol and placebo group (p value = 0.001). The first time for analgesic request was longer in dexmedetomidine group (p value = 0.001) and Hemodynamic parameters were significantly lower in tramadol and dexmedetomidine group (p value = 0.001). Sedation level was not significantly different between tramadol and dexmedetomidine group (p value = 0.001). CONCLUSION: According to the results peritonsillar infiltration of dexmedetomidine is effective and safe in relieving post-tonsillectomy pain.

Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study.

OBJECTIVE: Post-tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day-case tonsillectomy. METHODS: We compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post-tonsillectomy pain. Post-tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post-tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated. RESULTS: In the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P = 0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post-tonsillectomy bleeding in the two groups was not statistically different. CONCLUSION: We recommend celecoxib as a more suitable choice than acetaminophen for post-tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.

The effectiveness of a preoperative multi-component non-pharmacologic preparation on post-tonsillectomy pain: A randomized controlled clinical trial.

INTRODUCTION: Tonsillectomy is a painful operation and some studies have suggested that preoperative non-pharmacologic preparations may decrease postoperative pain. In this randomized clinical trial study, we decided to determine which is more effective in the post-tonsillectomy pain; an informative booklet or a costly, time consuming, sophisticated, and multi-component preparation program. MATERIALS AND METHODS: Patients were randomly assigned into two groups. In the booklet group, children and their parents only received an informative booklet as routine information preparation. On the other hand, in the multi-component group; in addition to receiving the same booklet, children and their parents received our multi-component pre-operative preparation program. The following items were included in the package: preoperative tour in the ward, an educational DVD, and therapeutic play intervention. All patients were observed at least for 8 h as a day case or ambulatory tonsillectomy. The pain score was recorded according to the visual analog scale for seven days. Finally, the post-tonsillectomy pain scores were compared in the two groups. The multi-component group included 121 children and booklet group 120. RESULTS: Minimum and maximum age was 9 and 12 years. Regarding post-tonsillectomy pain, we found no significant difference between the multi-component group and the booklet group. CONCLUSION: Our data revealed that a new concept which is more cost-effective and concise booklet is as effective as costly and sophisticated methods in post-tonsillectomy pain among 9-12 years old children.

Implications of a Retrospective Study on Weight-Based Risk for Post-Tonsillectomy Pain in Children.

PURPOSE: The purpose was to examine if children experience weight-based risks for post-tonsillectomy pain (PTP) in the postanesthesia care unit (PACU). DESIGN: This retrospective correlational cohort design included a sample of 180 children between the ages of 4 to 12 years who had tonsillectomy and adenoidectomy or tonsillectomy before August 2016; half were obese (OB) or overweight (OW). METHODS: The sample was obtained from children who had surgery at a large pediatric hospital with an attached outpatient surgical center in North Texas. Children were defined as either OB and OW or non-OB and non-OW based on a cutoff of standardized body mass index z scores of 85th percentile and greater per the National Center for Health Statistics. Pain scores were obtained in the PACU after surgery. Early PTP was defined as the most severe pain experienced by a child in the first 15 minutes after extubation. Prolonged PTP was sustained and uncontrolled pain in the PACU. FINDINGS: OB and OW status did not increase the likelihood of experiencing early PTP when examined by multiple logistic regression controlling for covariates (adjusted odds ratio, 1.391; P = .369). OB and OW status was associated with longer episodes of prolonged PTP (rs[178] = 0.16; P = .03). OB and OW children were more likely to experience prolonged PTP in the PACU (χ2[1] = 8.353; P = .004), with these children experiencing an average PTP period twice as long as their peers. CONCLUSIONS: OB and OW children did experience risk for prolonged PTP, averaging sustained pain for approximately twice as long as other children. The increased risk for prolonged PTP in OB and OW children occurred despite well-managed early PTP with rates that matched those of their peers. No weight-based risk for early PTP was observed. Further research is needed in the area of PTP management in OB and OW children.

Framework to Explain the Progression of Pain in Obese or Overweight Children Undergoing Tonsillectomy.

An estimated 100,000 obese (OB) and overweight (OW) children undergo tonsillectomy each year in the United States. Pain management in this population is particularly challenging because of weight-based dosing, clinician fears, potential for airway obstruction, and genetic differences. A framework is proposed to explain factors involved in the post-tonsillectomy pain (PTP) experience in OB and OW children. The tonsillectomy, the body's inflammatory state, and mechanical stressors comprise influencing factors in PTP progression. Clinician-delivered medication doses, genetic variants of drug metabolism, and soothing factors serve as mediating factors in the progression of PTP. Postanesthesia care unit (PACU) nurses may use this framework to better understand PTP progression in OB and OW children. PACU nurses may manipulate certain mediating factors discussed in this framework to moderate PTP progression in OB and OW children. Researchers may use this framework to support future research to improve PTP management in OB and OW children.

Tantum verde mouthwash for tonsillectomy: A prospective, double-blind, randomized control trial.

OBJECTIVES: Post-tonsillectomy pain control is still considered a challenge. Topical agents would seem to be an ideal, safe option. Our objective was to compare the efficacy of mouthwash preparation with anti-inflammatory, anesthetic, and analgesic properties (Tantum Verde®, 0.15% benzydamine hydrochloride) with that of placebo in improving post-tonsillectomy morbidity. METHODS: A prospective, double blind, randomized clinical trial was performed. Patients older than 12-years-of-age who underwent tonsillectomy were recruited. Participants were randomized into 2 groups to receive either 0.15% benzydamine hydrochloride (TV) mouthwash solution (study arm) or a placebo solution. They were instructed to gargle the intervention they received 3 times a day for 7 days following surgery. Primary outcomes were intensity and duration of post-operative pain (using VAS visual analogue score) during a 2-week follow-up period. Secondary outcomes were pain medication demand, readmission, incidence of post-operative bleeding, hospital stay duration, and time to resume normal solid diet. RESULTS: Thirty-nine patients completed the study, of whom 23 received TV and 16 received placebo. The mean age was 23.1 years. There was no significant difference between the groups in the primary or secondary outcomes. CONCLUSIONS: The data suggest that topical treatment with TV mouthwash solution was not found to be superior to placebo in the management of post-tonsillectomy pain, bleeding, and return to a regular solid diet. Further research studies should be designed to investigate the ideal treatment for reducing post-tonsillectomy morbidity. CLINICAL TRIAL REGISTRATION: NIH identifier: NCT02190762; IRB NHR002814.

Effect of paracetamol/prednisolone versus paracetamol/ibuprofen on post-operative recovery after adult tonsillectomy.

OBJECTIVE: To compare the effect of Paracetamol/Prednisolone versus Paracetamol/Ibuprofen on post-operative recovery after adult tonsillectomy. BACKGROUND: Various analgesic protocols have been proposed for the control of post-tonsillectomy morbidity with need for better control in adult population for having higher severity of post-operative pain and risk of secondary post-tonsillectomy bleeding. METHODS: This is a prospective cohort study conducted on 248 patients with age of 12 years or older distributed as two equal groups; the first one receiving Paracetamol/Prednisolone and the second one receiving Paracetamol/Ibuprofen. Both groups were compared at 7 days post-operative regarding pain at rest, tiredness of speech, dietary intake, and decrease in sleep duration. Both groups were compared regarding incidence of nausea and vomiting at 2 days post-operative. The incidence and severity of secondary post-tonsillectomy hemorrhage was compared between the two groups. RESULTS: Pain at rest (no swallowing - no talking) was less in group I but not reaching statistical significance (p = 0.36). In addition, dietary intake was better in group I but not reaching statistical significance (P = 0.17). However, talking ability was better with statistically significant difference (P = 0.03) in group I. Impairment of sleep was less with group II but not reaching statistical significance (p = 0.31). The incidence of vomiting at second post-operative day was less in group I with statistical significance (p = 0.049). The incidence of secondary post-tonsillectomy bleeding was significantly higher in group II with statistical significance (p = 0.046). The severity of bleeding episodes was also significantly higher in group II (p = 0.045). CONCLUSION: Both ibuprofen and prednisolone were effective as a part of post-operative medication regimen after adult tonsillectomy. However, prednisolone was superior to ibuprofen regarding improvement of pain at rest, dietary intake, tiredness of speech and post-operative nausea and vomiting. However, ibuprofen had a better impact on sleep. The incidence and severity of secondary post-tonsillectomy hemorrhage were significantly higher with ibuprofen favoring the selection of prednisolone to be combined with paracetamol in the post-operative medication protocol following tonsillectomy.

Comparing the effects of peritonsillar infiltration of tramadol before and after the surgery on post-tonsillectomy pain.

The aim of the study was to compare the effects of peritonsillar infiltration of tramadol before and after the surgery on post-tonsillectomy pain. In this double-blinded clinical trial study, 80 children aged 5-12 years old with ASA (American Society of Anesthesiologists) class I or II undergoing tonsillectomy involved. In group A (n = 40), after anesthesia induction and before starting the surgery, tramadol 2 mg/kg diluted in normal saline up to 2 cc total volume was injected into the tensile bed by the anesthesiologist using a 25 gauge needle. Surgery began 3 min later and the tonsils were removed using the sharp dissection method. In children of group B (n = 40), anesthesia induction was performed. When surgery was completed, tramadol 2 mg/kg diluted in normal saline up to 2 cc total volume was injected at the site of removing each tonsil using a 25 gauge needle by the anesthesiologist. Using the CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) Scale, pain recorded at different times. Patient sedation was recorded using the RAMSAY Sedation Scale. All the data were analyzed using SPSS 17 statistical software. Two groups significantly felt different pain intensities at different times following the surgery. At the three times, the mean sedation score in the group receiving tramadol infiltration before surgery was a little higher compared to the other group, but this difference was not significant (p > 0.05). As for the relative frequency of nausea and vomiting, the difference was not significant (p = 0.793). Request for analgesics between the groups was not significant (p = 0.556). The mean time of the first feeding after the surgery was not significant between the groups (p = 0.062). Surgical duration was almost the same for both groups (p > 0.05). Systolic blood pressures (before surgery, before extubation, and after extubation) were statistically the same in both groups (p < 0.05). Furthermore, systolic blood pressures 10, 15, and 30 min after entry into the recovery room were the same in both groups. We concluded that peritonsillar infiltration of tramadol before surgery controlled postoperative pain better from 8 h after the surgery to hospital discharge (late effect), but that local infiltration of tramadol after surgery controlled postoperative pain better up to 2 h after the operation (early effect).

The effect of local injection of epinephrine and bupivacaine on post-tonsillectomy pain and bleeding.

INTRODUCTION: Tonsillectomy is one of the most common surgeries in the world and the most common problem is post-tonsillectomy pain and bleeding. The relief of postoperative pain helps increase early food intake and prevent secondary dehydration. One method for relieving pain is peritonsillar injection of epinephrine along with an anesthetic, which has been shown to produce variable results in previous studies. Study Deign: Prospective case-control study. SETTING: A tertiary referral centers with accredited otorhinolaryngology-head & neck surgery and anesthesiology department. MATERIALS AND METHODS: Patients under 15 years old, who were tonsillectomy candidates, were assigned into one of three groups: placebo injection, drug injection before tonsillectomy, and drug injection after tonsillectomy. The amount of bleeding, intensity of pain, and time of first post-operative food intake were evaluated during the first 18 hours post operation. RESULTS: The intensity of pain in the first 30 minutes after the operation was lower in the patients who received injections, but the difference was not significant during the first 18 hours. The intensity of pain on swallowing during the first 6 hours was also lower in the intervention groups as compared with the placebo group. The amount of bleeding during the first 30 minutes post operation was lower in the two groups who received injections, but after 30 minutes there was no difference. CONCLUSION: Injection of epinephrine and bupivacaine pre- or post- tonsillectomy is effective in reducing pain and bleeding. The treatment also decreases swallowing pain in the hours immediately after surgery.

Clinical Comparison of Post-Tonsillectomy Pain : Tonsillectomy Using Cold Instrument Versus Tonsillectomy Using Electrocautery

BACKGROUND AND OBJECTIVES: Tonsillectomy is one of the most common operations in otolaryngology and is performed with various surgical techniques. It seems that there is no superior technique regarding post-tonsillectomy pain. We attempted to identify preferable methods of tonsillectomy in clinical practice by comparing the levels of postoperative pain. MATERIALS AND METHODS: Between June 2009 and Jan 2010, 80 cases of tonsillectomy were performed. In Group A (age : 10-15 years, 40 cases), 20 cases involved tonsillectomy via snare. The other 20 underwent tonsillectomy using electrocautery. The same surgical division was applied in Group B (25-40 ages, 40 cases). All tonsillectomies were performed under general anesthesia by the same surgeon. RESULT: The mean duration of postoperative pain after tonsillectomy by snare and tonsillectomy by electrocautery in Group A was 5.2+/-2.1 and 6.7+/-3.7, respectively. The mean duration of postoperative pain after tonsillectomy by snare and tonsillectomy by electrocautery in Group B was 7.4+/-1.4 and 10.8+/-3.2, respectively. The results indicate that electrocautery is the more painful method of the two tested methods. The difference in post-tonsillectomy pain was statistically significant between the surgical methods. CONCLUSION: It seems that snare tonsillectomy is a useful method for reducing post-tonsillectomy pain compared with that after electrocautery tonsillectomy.