Effect of tonsillar fossa closure on postoperative pain and bleeding risk after tonsillectomy

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Abstract

Objective

To determine if closing the tonsil fossa after tonsillectomy leads to less pain and bleeding.

Study design

Interventional, Randomized, Single Blind, Active Control, Single Group Assignment, Safety/Efficacy Study. Follow-up: 2 months.

Methods

Generalized Estimating Equations (GEE) analyzed effects of tonsillar pillar closure, surgeon experience and interaction on outcomes.

Setting

Primarily academic tertiary care referral center, institutional practice, primarily children, both ambulatory and hospitalized care.

Subjects

763 subjects (age 8–264 months) undergoing tonsillectomy.

Exclusions

suspected malignancy or active peritonsillar abscess. At the discretion of the attending surgeon, patients undergoing tonsillectomy during the 4 year study period were offered participation. A computer selected the side closed. 131 subjects withdrew (complete lack of follow-up information) after the first 72 h.

Intervention

3-0 chromic sutures on tapered needles to close one tonsillar fossa. The subject was not told which side was closed.

Main outcome measures

postoperative bleeding (at any time) and pain reported was sought on days 1, 7, 14, 21, and 28.

Results

Closure of the tonsillar fossa did not change the risk of bleeding. Closing the tonsillar fossa had a 40% increase in the odds ratio of postoperative pain. In the tonsillar fossa sides left open, greater surgeon experience decreased the risk of bleeding. In closed sides, enriched surgeon experience increased the risk of bleeding (p < .0.05).

Conclusions

Suture closure of the tonsillar fossa after tonsillectomy does not reduce the risk of bleeding. Additionally, closing the tonsillar fossa increased postoperative pain.

Level of evidence

1b (individual randomized controlled trial).

Introduction

Tonsillectomy is one of the most common operations performed by otolaryngologists [1], [2] 287,000 tonsillectomies (with or without adenoidectomy) were performed in 1996 on children under 15 years of age, almost doubling to 530,000 in 2006 [1], [2], [3]. This represents roughly $701 million/year for tonsillectomy in the United States alone [4]. Techniques to improve the experience for the patient by having better outcomes and lowering risks and discomfort, as well as making the operation and postoperative care easier for the surgeon have been sought for decades, if not centuries [5].

This paper is not focused on the differences between techniques of removal, but on a method to reduce postoperative complications after complete tonsillectomy. The specific method chosen here to test is suturing together of the tonsillar pillars to close the tonsillar fossa. Immediate wound closure allows for healing by primary intention, which is faster than allowing the wound to close spontaneously by secondary intention healing. Mechanical integrity of a healed wound allows for quicker return to normal function [6].

The feasibility and value of tonsillar fossa closure has been studied by several investigators. Weighill et al. [7] evaluated 60 consecutive adult (age greater than 16 years) subjects, and by randomization, sutured one side closed after tonsillectomy with 3-0 plain catgut. Weighill placed 3 interrupted sutures to approximate the anterior and posterior tonsillar pillars. No statistically significant difference was noted between the sewn and unsewn sides at postoperative days 1, 2, and 3. More than half the subjects were lost to follow up at 6 weeks postoperatively. 3 Subjects developed a palatal hematoma on the sutured side, while one subject had a postoperative hemorrhage from the unsutured side.

Nandapalan and McIlwain [8] compared 50 consecutive adult patients (age greater than 15 years) undergoing tonsillectomy, and by randomization, sutured one side closed with 2-0 polydioxanone (PDS), with 3 interrupted sutures, sewing the pillars to the tonsillar fossa bed to eliminate dead space. The sutured side was more painful at postoperative days 1, 2, and 3, but thereafter the unsutured side was more painful at postoperative days 4–10. Eighteen of 19 patients complained of otalgia on the unsutured side. None had a palatal hematoma and 1 had mild postoperative hemorrhage from the unsutured side.

Ramjettan and Singh [9] compared two non-randomized, consecutive groups: an initial control group of 20 whose tonsillar pillars were not sewn, and a second experimental group of 20 whose tonsillar pillars were sewn with 3-0 chromic catgut in a running, continuous fashion, bilaterally. The ages ranged from 3 to 35 years. The adults had more pain than the children in both groups at the immediate postoperative measurement and at the 24-h point. The difference in pain scores for the two groups (control vs. treatment) was not statistically significant. In the sutured group, 2 subjects had palatal hematomas, and one subject had temporary nasal regurgitation. No subjects had postoperative bleeding.

Genc et al. [10] in 39 patients, ages 3–15 years, at the preference of the attending surgeon, selected one tonsillar fossa to be sutured closed with 4-0 plain catgut on a sharp needle in 4–5 interrupted sutures. Genc et al. found no difference in pain on the first postoperative day. However, in contrast to the above studies, pain was less on the sutured side from postoperative days 3–10. Edema was worse on postoperative day 10 on the sutured side, but healing was better. None of the subjects had palatal hematomas, or postoperative bleeding reported, however the subjects were not followed beyond postoperative day 10. The sutured side was statistically significantly more likely to have edema.

The above studies suffer from small sample sizes, and included primarily adults. This study was undertaken to prospectively and systematically investigate whether a simple technique could be used to reduce complications in a large group of children undergoing tonsillectomy in a randomized trial of closed vs. open tonsillar fossa.

Section snippets

Aims and objectives

The long-range goal is to implement safe and effective surgical strategies when tonsillectomy is performed. The paper investigates a specific surgical technique in an effort to reduce postoperative complications by suture closure of the tonsillar pillars. Closed wounds require “less healing”, as the body does not have to bring the wound edges together, and thus the raw surfaces are not exposed to abrasive disruptions.

Institutional review and subject protection

This study was approved by the Institutional Review Board (IRB) of our institution (Indiana University Office of Research Administration, Human Subjects Office), and monitored annually by the IRB. This clinical trial was registered with http://www.clinicaltrials.gov.

Inclusion criteria

Our inclusion criteria were: any patient, male or female, of any ethnicity, or any age, for whom tonsillectomy was recommended for recurrent pharyngitis, obstructive sleep disorder, snoring, halitosis, or feeding difficulty

Results

The CONSORT 2010 Flow Diagram is show in Fig. 1.The demographic description of the subjects who met the criteria for this study and enrolled is presented in Table 1 with the age distribution in Fig. 2. The categorization of the operations is listed in Table 2. Surgeon data are listed in Table 3. Seventeen interviewers collected postoperative information about the subjects.

Discussion

This study was designed to evaluate the effect of suture closure of one tonsillar fossa after tonsillectomy on postoperative pain and bleeding.

Conclusions

The data show that the use of suture closure of the tonsillar pillars after tonsillectomy does not reduce the risk of bleeding. In fact, in tonsillar fossae left open, the more experienced the surgeon, the lower the risk of bleeding. In closed tonsillar fossae, the more experienced the surgeon, the higher the risk of bleeding. This finding is counter-intuitive, as one would expect more experience to lead to less bleeding, and better suturing. Additionally, closing the tonsillar pillar increased

Funding

Funding for biostatistical services was provided by the General Otorhinolaryngological Foundation, Indianapolis, IN.

Conflict of interest statement

The authors have no conflicts of interest to report.

Acknowledgments

The authors gratefully acknowledge the contributions of the other attending surgeons: M.S. Chand, S.R. Cordes, M.H. Fritsch, R.A. Hamaker, R.C. Miyamoto, A.O. Yekinni, the School of Medicine, Department of Otolaryngology – Head and Neck Surgery residents, nurses, secretaries and phone-interviewers, for this study.

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