International Journal of Pediatric Otorhinolaryngology
Effect of tonsillar fossa closure on postoperative pain and bleeding risk after tonsillectomy
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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Efficacy of pillar suture for post-tonsillectomy morbidity in children: a meta-analysis
2021, Brazilian Journal of OtorhinolaryngologyCitation Excerpt :There have been reports that pillar suture can reduce postoperative pain and bleeding.8–10 However, the necessity of the pillar suture is debatable since there have been studies showing conflicting results.11,12 It is important to have a comprehensive understanding of the various criteria and results that determine the effectiveness of pillar suture.
Postoperative hemorrhage following coblation tonsillectomy with and without suture: A randomized study in Chinese adults
2021, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :A previous study reported that the use of suture combined with Surgicel Absorbable Hemostat increased pain but decreased bleeding incidence during the postoperative period [16]. Another study showed that suture closure of the tonsillar fossa after tonsillectomy did not reduce the risk of bleeding and increased postoperative pain [17]. Nevertheless, the patients that in these two studies underwent more than one kind of surgery.
Does suturing tonsil pillars post-tonsillectomy reduce postoperative hemorrhage?: A literature review
2019, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Matt et al. performed tonsillectomies either via electrocautery dissection, cold dissection and snare, or harmonic scalpel with majority (99%) of the tonsillectomies being performed with electrocautery dissection. There were 763 subjects in a randomized single group trial in which tonsillectomies were performed and only one tonsil pillar was sutured using 2–3 interrupted chromic sutures with the open tonsil fossa serving as the control [14]. Postoperative bleeding occurred in 5.6% of the patients.
Reducing the exposure of the tonsillar fossa does not impact postoperative pain levels in children undergoing tonsillectomy: A double-blind randomized controlled trial
2018, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Only one previous study compared the effectiveness of suturing the tonsillar fossa in reducing pain using the pain assessment tool used in our study [24]. Some studies reported pain by simply asking the patients to identify its location, while others used simplified visual analogue scales [21,23,25,26]. In addition, the same surgeon performed the procedures using similar instruments and supplies in all patients.
Bleeding after tonsillectomy
2017, Operative Techniques in Otolaryngology - Head and Neck SurgerySignificantly reducing post-tonsillectomy hemorrhage requiring surgery by double-layer suture: A retrospective analysis
2020, American Journal of Otolaryngology - Head and Neck Medicine and Surgery