Can mucosal sealing reduce tonsillectomy pain?

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Summary

Objective/hypothesis

The hypothesis tests whether sealing the tonsillectomy field with posterior pillar mucosa can prevent unwanted outcomes in pediatric tonsillectomy.

Study design

A prospective, randomized, single blinded study was conducted on a sample of 39 children between 3 and 15 years of age. After dissection and snare tonsillectomy, the tonsillar fossa was covered on one side using the palatopharyngus mucosa and the other side is used as control. Pain scores, healing, edema and infection at the operation site were investigated.

Methods

The tonsillectomy sites were randomly assigned into one of two groups. First group contained the ones with mucosal flap sealed over the operation site and the second group was kept as control with the operation site left uncovered. All of the patients received mild analgesics. The pain assessment is done on Days 1, 3, 5, 7 and 10 postoperatively, by using Wong-Baker faces visual analog scale. On the 10th postoperative day, the operation field of each side is scored separately for edema, healing and infection. Statistical investigation was performed through a software program.

Results

On first postoperative day, pain level difference was not statistically significant between the two groups (p > 0.01). But from 3rd to 10th postoperative day, the pain level was found out to be lower in the mucosa sealed site (p < 0.01). On the 10th postoperative day, while the edema was significantly more (p < 0.01), healing was better (p < 0.01) at the sutured site. Postoperative infection at operation site was not different between the groups (p > 0.01).

Conclusion

Covering tonsillectomy field with mucosal palatopharyngeal arch flap significantly reduces pain after third postoperative day. The flap side had better healing when compared to denuded site. But the sutures in the mucosal flap may cause more tissue edema. Sutures have no significant effect on postoperative infection. Thus, mucosal flap may be used as an adjuvant surgical technique to decrease tonsillectomy pain of children in addition to the analgesic medication.

Introduction

Although tonsillectomy is the most frequent operation performed on the pediatric population, postoperative pain relief is still a problem for the patients, families and surgeons. Especially in the first 3 days after the operation, pain is a significant problem [1]. There are various analgesic medications for pain management, the spectrum of which varies from acetaminophen to narcotic analgesics each with their own advantages and disadvantages. Sometimes acetaminophen can be ineffective for pain control and a need may arise for the use of non-steroid anti-inflammatory drugs although they carry the risk of increasing bleeding time and lead to the most feared complication of tonsillectomy: the postoperative bleeding. Besides postoperative medication, various surgical techniques can be used for pain control. Some of these techniques are as follows: classical cold knife dissection, hot knife, laser assisted tonsillectomy, using powered instruments, the coblation method and fibrin sealing the operation site [2], [3], [4], [5], [6]. But there are controversial arguments about their effectiveness on the postoperative pain control.

The pain is a protective mechanism of the body which alerts the organism to get rid of the stimulus that causes it. It is a significant indicator that measures the postoperative comfort of the patients. But the reliability of pain assessment is questionable for its tendency of subjective perception. The methods used for pain assessment are visual analog scales, numeric pain intensity scales, simple descriptive pain intensity scales, graphic rating scales, verbal rating scales, pain faces scales, numeric pain intensity and pain distress scales, brief pain inventories, and memorial pain assessment cards [7]. Understanding the extent of the pain suffered by the patients is crucial for the physicians to come up with an appropriate decision to relieve the pain. Pain assessment and pain management are becoming more important issues in today's modern medicine and are used as important indicators for many accreditation programs under total quality management applications of the hospitals.

The aim of this paper is to search for the effectiveness of a surgical method over the pain after tonsillectomy operations in pediatric patients. The surgical method is modified slightly. Once the method is found to be effective in pain management, this will lead to less hospital day stays, less medication for pain control, shorter recovery period and as a result more parent satisfaction from the operation.

Section snippets

Materials and methods

The study had been performed between 2001 and 2004. Thirty-nine patients between 3 and 15 years old were enrolled into the study. Parental informed consents were obtained. Children under 3 years of age were excluded because of difficulty with reliable participation in the pain questionnaire. Each patient has either tonsillectomy because of chronic tonsillitis, or adenoidectomy with tonsillectomy because of adenotonsillar hypertrophy with chronic infection, or adenoidectomy with tonsillectomy

Results

The age range of patients is between 3 and 15 with a mean of 6.98 years. There are 22 (56.4%) male and 17 (43.6%) female patients. Posterior tonsil pillar mucosa is laid over the tonsillectomy site at 14 (35.9%) right and 25 (64.1%) left sides. All of the attending surgeons were right handed and it was easier for them to suture the left side and this makes the difference between the percentages of the right and left sides. For the overall cases the average time for suturing the mucosa over the

Discussion

Pain assessment after tonsillectomy operations must be included in the routine post-tonsillectomy physical assessment of the patients. The intense pain itself can have adverse effect both on the heart rate and blood pressure of the patient. The pain which the body senses acting via the sympathetic autonomous nervous system may increase the heart rate, and the blood pressure. Both of these effects causes a high cardiac output and thus leads to postoperative exhaustion of the patient. In addition

Conclusion

Tonsillectomy is the most frequently performed operation on the children and still it causes significant pain for the child. There are various methods in surgical techniques and different classes of medications to overcome the pain problem. But none of them could able to completely cease the pain perception after the operation. Combination of them can help the suffering child and differences in surgical techniques can be an adjunctive to the analgesics. The surgical method of sealing the

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