Association of Vibrotactile Biofeedback With Reduced Ergonomic Risk for Surgeons During Tonsillectomy.

Importance: Work-related musculoskeletal disorders are common among otolaryngologists and can be associated with decreased productivity, missed workdays, and reduced quality of life. Ergonomic risk for surgeons is elevated during common otolaryngology procedures; current ergonomic interventions lack the ability to provide real-time feedback. The ability to quantify and mitigate ergonomic risk during surgery may reduce work-related musculoskeletal disorders. Objective: To quantify the association of vibrotactile biofeedback with intraoperative ergonomic risk to surgeons during tonsillectomy. Design, Setting, and Participants: This cross-sectional study was conducted between June 2021 and October 2021 at a freestanding tertiary care children's hospital and included 11 attending pediatric otolaryngologists. Data analysis was conducted from August to October 2021. Interventions: Real-time quantification of ergonomic risk during tonsillectomy and the use of a vibrotactile biofeedback posture monitor. Main Outcomes and Measures: Association of vibrotactile biofeedback with objective measures of ergonomic risk. Assessment tools included the Rapid Upper Limb Assessment, craniovertebral angle, and time spent in an at-risk posture. Results: Eleven surgeons (mean [SD] age 42 [7] years; 2 women [18%]) performed 126 procedures with continuous posture monitoring in the presence (80 [63%]) and absence (46 [37%]) of vibrotactile biofeedback. No complications or delays associated with the device were reported. Intraoperative vibrotactile biofeedback was associated with improved Rapid Upper Limit Assessment neck, trunk, and leg scores by 0.15 (95% CI, 0.05-0.25), improved craniovertebral angle by 1.9 (95% CI, 0.32-3.40), and decreased overall time spent in an at-risk posture by 30% (95% CI, 22%-39%). Conclusions and Relevance: The results of this cross-sectional study suggest that use of a vibrotactile biofeedback device to quantify and mitigate ergonomic risk for surgeons is feasible and safe while performing surgery. Vibrotactile biofeedback was associated with reduced ergonomic risk during tonsillectomy and may have a role in improving surgical ergonomics and preventing work-related musculoskeletal disorders.

The effect of honey on post-tonsillectomy pain relief: a randomized clinical trial.

OBJECTIVE: The study aimed to evaluate the effects of honey on the incidence of post-operative pain in patients undergoing tonsillectomy. METHODS: This study is a double-blind and randomized controlled trial design. Twenty-four adult male patients underwent tonsillectomy surgery and were randomized assigned into three groups consist of honey group, placebo group, and control group. All subjects were given standard analgesia and antibiotics, also honey for the honey group and placebo for the placebo group, and only standard post-operative regimens for the control group. This study used silk-cotton tree or kapok tree honey (Ceiba pentandra). Honey was used by gargling every six hours for ten days. Likewise, the same method was applied in the placebo group. Pain scale was assessed for ten days using the Visual Analogue Scale questionnaire, and the frequency of analgesic drugs was recorded on days 1, 2, 4, 7, and 10. RESULT: Honey group showed significantly higher pain reduction when compared to placebo and control groups, with a significant reduction in the pain scale on day 1, 2, 4, 7 and 10 (p = 0.034; p = 0.003; p < 0.001; p = 0.001; p = 0.001) gradually; Significant differences were also observed in analgesic use, especially on day 2, 4 and 7 (p = 0.028; p = 0.001; p = 0.003). CONCLUSIONS: Administration of Kapok tree honey (C. pentandra) after tonsillectomy might reduce post-operative pain and reduce the need for analgesia. Therefore, honey can be considered a complementary medicine and can be administered routinely as adjunctive therapy for post-operative patients.

Clinical utility of local over general anesthetic tonsillectomy using the BiZact™ device.

PURPOSE: Tonsillectomy under general anesthesia may be viewed preferentially to local anesthesia, due to mitigation of potential airway compromise secondary to intraoperative hemorrhage, patient discomfort and anxiety. However, this is offset by risk of increased trauma (via the endotracheal tube and gag), adverse medication reactions and cost. Here we evaluated the case for use of local anesthesia in tonsillectomy using the BiZact™ (Medtronic) device by comparing surgical outcomes and cost factors across patients where either local or general anesthesia was employed. MATERIALS AND METHODS: Retrospective cohort study of 59 BiZact™ tonsillectomy patients (38 under local anesthetic, and 21 under general anesthetic) from a single surgeon at Tauranga Hospital (public) and Grace Hospital (private) in New Zealand; March 2018 to June 2021. RESULTS: Neither patient group had any primary postoperative hemorrhage and there was comparable incidence of secondary hemorrhage (one case in each cohort). Local anesthetic tonsillectomy was well tolerated with only 2 patients requiring conversion to general anesthetic secondary to anxiety. Local anesthetic proved to be cost-effective, with a halving of hospital length of stay and significant associated overall cost saving, and did not add significantly to operating or total theatre time. Local anesthetic tonsillectomies where perioperative sedation was not required were associated with additional reductions in recovery and overall hospital stay, and cost. CONCLUSIONS: Local anesthetic BiZact™ tonsillectomy is evidently safe and cost-effective.

Time to Functional Recovery After Laser Tonsillotomy Performed Under Local Anesthesia vs Conventional Tonsillectomy With General Anesthesia Among Adults: A Randomized Clinical Trial.

Importance: Carbon dioxide laser tonsillotomy performed under local anesthesia may be an effective and less invasive alternative than dissection tonsillectomy for treatment of tonsil-related afflictions. Objective: To compare functional recovery and symptom relief among adults undergoing tonsillectomy or tonsillotomy. Design, Setting, and Participants: This randomized clinical trial was conducted at 5 secondary and tertiary hospitals in the Netherlands from January 2018 to December 2019. Participants were 199 adult patients with an indication for surgical tonsil removal randomly assigned to either the tonsillectomy or tonsillotomy group. Interventions: For tonsillotomy, the crypts of the palatine tonsil were evaporated using a carbon dioxide laser under local anesthesia, whereas tonsillectomy consisted of total tonsil removal performed under general anesthesia. Main Outcomes and Measures: The primary outcome was time to functional recovery measured within 2 weeks after surgery assessed for a modified intention-to-treat population. Secondary outcomes were time to return to work after surgery, resolution of primary symptoms, severity of remaining symptoms, surgical complications, postoperative pain and analgesics use, and overall patient satisfaction assessed for the intention-to-treat population. Results: Of 199 patients (139 [70%] female; mean [SD] age, 29 [9] years), 98 were randomly assigned to tonsillotomy and 101 were randomly assigned to tonsillectomy. Recovery within 2 weeks after surgery was significantly shorter after tonsillotomy than after tonsillectomy (hazard ratio for recovery after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.5). Two weeks after surgery, 72 (77%) patients in the tonsillotomy group were fully recovered compared with 26 (57%) patients in the tonsillectomy group. Time until return to work within 2 weeks was also shorter after tonsillotomy (median [IQR], 4.5 [3.0-7.0] days vs 12.0 [9.0-14.0] days; hazard ratio for return after tonsillectomy vs tonsillotomy, 0.3; 95% CI, 0.2-0.4.). Postoperative hemorrhage occurred in 2 patients (2%) in the tonsillotomy group and 8 patients (12%) in the tonsillectomy group. At 6 months after surgery, fewer patients in the tonsillectomy group (25; 35%) than in the tonsillotomy group (54; 57%) experienced persistent symptoms (difference of 22%; 95% CI, 7%-37%). Most patients with persistent symptoms in both the tonsillotomy (32 of 54; 59%) and tonsillectomy (16 of 25; 64%) groups reported mild symptoms 6 months after surgery. Conclusions and Relevance: This randomized clinical trial found that compared with tonsillectomy performed under general anesthesia, laser tonsillotomy performed under local anesthesia had a significantly shorter and less painful recovery period. A higher percentage of patients had persistent symptoms after tonsillotomy, although the intensity of these symptoms was lower than before surgery. These results suggest that laser tonsillotomy performed under local anesthesia may be a feasible alternative to conventional tonsillectomy in this population. Trial Registration: Netherlands Trial Register Identifier: NL6866 (NTR7044).

Addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia improves analgesic efficacy after tonsillectomy and adenoidectomy: A randomized controlled trial.

OBJECTIVES: The aim of this study was to determine whether the addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia was more effective than ropivacaine alone in attenuating pain after tonsillectomy and adenoidectomy. METHODS: This was a double-blind randomized clinical trial. One hundred and twenty children scheduled for tonsillectomy and adenoidectomy using a combination of general anaesthesia and local infiltration anaesthesia were randomized into the dexmedetomidine plus ropivacaine group (DR) and ropivacaine group (R). The children were locally infiltrated with 1 µg kg-1 dexmedetomidine and 0.25% ropivacaine in the DR group or 0.25% ropivacaine alone in the R group. In both groups, local infiltration anaesthesia was performed using 5 ml of solution. The pain scores were recorded at the 1st, 4th, 8th, 12th, 16th, 20th, and 24th hours after surgery using the Face Legs Activity Cry Consolability (FLACC) scale. When the pain score exceeded 4, paracetamol syrup (15 mg kg-1) was administered as a rescue analgesic. Time to the first administration of analgesic was recorded. RESULTS: 8th, 16th, 20th, and 24th hours after surgery, the children in the DR group had lower pain scores than those in the R group (P<0.05). The time to the first administration of analgesic was significantly longer in the DR group (mean: 10.4 h, range: 9.4-11.4 h) than in the R group (mean: 8.1 h, range: 7.3-8.8 h) (P < 0.001). CONCLUSION: The addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia effectively improved the efficacy of analgesia and extended the duration of analgesia after tonsillectomy and adenoidectomy.

The effect of adjuvant oral application of honey in the management of postoperative pain after tonsillectomy in adults: A pilot study.

OBJECTIVE: To analyze the effect of adjuvant oral application of honey for treating postoperative pain after tonsillectomy. DESIGN: Single centre prospective cohort study. SETTING: Two cohorts of patients after tonsillectomy. PARTICIPANTS: 56 patients treated with honey 8 times per day (honey group), 18 patients treated without honey (control group); baseline analgesia were non-steroidal anti-inflammatory drugs (NSAID) or coxibs; opioids were used as pro re nata (PRN) medication; mean age 34.4 ± 13.4 years; 36% women. MAIN OUTCOME MEASURES: On first to fifth postoperative day, patients rated their pain using the validated questionnaire of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale (NRS, 0-10) for determination of patient's pain. QUIPS allows standardized assessment of patients' characteristics andpain-associated patient-reported outcomes (PROs). The influence of preoperative and postoperative parameters on patients' postoperative pain were estimated by univariate and multivariate statistical analysis. RESULTS: Average pain in activity in the control group was greater than 4 (NRS 4.4 ± 2.4) during the first five postoperative days, with a renewed increase in pain intensity on the fifth day (4.3 ± 2.5). In the honey group, the pain in activity decreased without any further pain increase and was only higher than 4 on the first three postoperative days (4.3 ± 2.1, all p>0.05). However; neither minimal nor maximal pain were significantly different between both groups on the first postoperative day (p = 0.217, p = 0.980). Over the five postoperative days, the minimal and maximal pain in the honey group decreased continuously and faster than in the control group. With regard to pain-related impairments on the first day, the honey group reported less pain-related sleep disturbance (p = 0.026), as well as significantly fewer episodes of postoperative oral bleeding (p = 0.028) than the control group. Patients without honey consumption had on the first and fifth postoperative day a higher risk of increased minimal pain (OR = -2.424, CI = -4.075 --0.385). Gender was an independent factor for compliance of honey consumption on the second postoperative day (p = 0.037). Men had a lower probability for compliance of honey consumption (OR = -0.288, CI = -2.863 --0.090). CONCLUSION: There was a trend of reduced postoperative pain after oral honey application. Honey also seems to reduce pain-related impairments. The need for additional opioids on the first day could be reduced. A larger controlled trial is now needed to varify the effect of honey on pain after tonsillectomy. CLINICAL TRIAL REGISTRATION NUMBER: German Clinical Trials Register DRKS00006153. The authors confirm that all ongoing and related trials for this drug/intervention are registered.

Ketofol performance to reduce postoperative emergence agitation in children undergoing adenotonsillectomy.

Background: Emergence agitation is a reformed state of mindfulness, which starts with a sudden form of anesthesia and progresses through the early repossession age. Thus, the purpose of this study is to evaluate 1:3 ketofol performance on children 3-15 years old undergoing adenotonsillectomy.Methods: A total of 60 children aged 3-15 years undergoing adenotonsillectomy were randomly allocated to receive low-dose ketamine 0.15 mg/kg followed by propofol 0.45 mg/kg i.v. ketofol (1:3) about 10 min before the end of surgery in comparison to 60 children aged 3-15 years who received only normal saline and dextrose. Anesthesia was induced and maintained with sevoflurane. Postoperative pain and EA were assessed with objective pain score (OPS) and the Pediatric Anesthesia Emergence Delirium (PAED) scale, respectively. EA was defined as a PAED 10 points. Recovery profile and postoperative complications were also recorded.Results: The incidence and severity of EA were found significantly lower in the ketofol group in comparison to the control group with a percentage of (13.33% vs 48.33%) (8% vs 15%) respectively (P < 0.05). Also, the time for interaction from anesthetic tainted to extubating in the ketofol set was significantly less than in the control group (P < 0.05). Interestingly, there are no opposing events such as nausea, laryngospasm, bronchospasm, hypotension, bradycardia, bleeding, or postoperative respiratory depression (respiratory rate: <16) were noticed in the ketofol supervision (P > 0.05). Moreover, the heart rate was meaningfully higher in the control group starting at the time of tracheal extubating in comparison to the children undergone ketofol (P < 0.05). Alert score and time from painkilling tainted till liberation from PACU showed substantial significant changes at ketofol set (P < 0.05).Conclusion: Ketofol (1:3) shows significant performance to reduce postoperative agitation in the children undergone adenotonsillectomy.

Comparison of needle aspiration versus incision and drainage under local anaesthesia for the initial treatment of peritonsillar abscess.

PURPOSE: The treatment of peritonsillar abscess (PTA) is still controversial regarding the best method of drainage to perform. This study aims to compare effectiveness and safety of needle aspiration versus incision and drainage under local anaesthesia for the initial treatment of PTA. METHODS: A retrospective review of patients (age > 15 years) admitted in two tertiary medical centres for a PTA between November 2010 and October 2016 was performed. Patients were divided into two groups according to the type of drainage: needle aspiration or incision and drainage, under local anaesthesia. The primary outcome was the length of hospital stay; the need to repeat the procedure or to go to the operating room was also assessed. Complications or adverse events were listed in each group to assess safety. RESULTS: Over a 6-year period, 182 patients were admitted for a PTA and included in the analysis, with 82 patients in the aspiration group and 100 patients in the incision group. Mean age was 36.3 years, with a sex ratio of 1.33. The length of hospital stay ranged from 1 to 7 days (mean 2.7 days, median 2 days) with a median length of stay of 3.0 days (interquartile range 2-4) in the aspiration group versus 2.0 days (IQR 2-3) in patients who underwent incision and drainage (p = 0.009). A repetition of the needle aspiration was made for 46.3% of patients versus 10% of repetition of the procedure in the incision group (p = 0.0001). 12 patients (14%) of the aspiration group and 4 patients (4%) of the incision group required an additional drainage under general anaesthesia (p < 0.001). We found no differences regarding safety in both groups. CONCLUSION: Our study showed a significant decrease in the length of hospital stay in patients admitted for a PTA who underwent an initial incision and drainage under local anaesthesia, compared to needle aspiration, as well as a lower risk of repeating the procedure. A well-designed prospective and randomized study on a larger sample of patients is required to support these findings.

Could digital photography be an alternative to postoperative physical examination for pediatric tonsillectomy patients?

OBJECTIVE: To evaluate and compare the efficacy of postoperative control with digital photographs and physical examination for children who underwent tonsillectomy? METHODS: In this prospective study, 86 children (46 boys (53.5%) and 40 girls (46.5%) were enrolled for postoperative clinical visit and for obtaining photographs of the tonsillar bed with a digital camera at clinic control. RESULTS: No difference in tonsillar fossa healing was observed between the two methods 2 weeks after surgery. CONCLUSIONS: Digital photographs proved to be a safe method for postoperative control of pediatric patients who underwent tonsillectomy. Adding control with outpatient follow-up will be useful for minimizing postoperative complications.

Bupivacaine infiltration in children for postoperative analgesia after tonsillectomy: A randomised controlled trial.

BACKGROUND: Adenotonsillectomy is a frequently performed procedure in paediatric day-case surgery. Postoperative pain can be significant and standard analgesia protocols are often insufficient. OBJECTIVE: Our primary objective was to investigate if infiltration of the peritonsillar space with bupivacaine would reduce the need for postoperative opioids compared with pre-emptive intravenous tramadol. DESIGN: A double-blind, randomised controlled trial. SETTING: Ambulatory surgical day care centre, University Hospitals of Leuven, Belgium, from January 2012 to September 2016. PATIENTS: Two hundred children, between 4 and 10 years old, undergoing elective adenotonsillectomy were included in the study. INTERVENTION: Children were randomly allocated to receive either a bolus of 3 mg kg intravenous tramadol or infiltration of the tonsillar lodge with 5-ml bupivacaine 0.25%. Reasons for exclusion were American Society of Anesthesiologists classification greater than 2, allergies to the investigated products, psychomotor retardation, bleeding disorders and lack of proficiency in Flemish. MAIN OUTCOME MEASURES: The primary endpoint was the number of children in need of piritramide postoperatively. Secondary outcomes included the cumulative dose of postoperative piritramide, pain scores and the incidence of postoperative nausea and vomiting during the first 24 postoperative hours, time to discharge and adverse effects. RESULTS: The proportion of children in need of postoperative piritramide was significantly lower in the tramadol group than in children with peritonsillar infiltration (57 vs. 81%, P < 0.001). When in need of postoperative piritramide, the tramadol-group required a significantly lower dose (median [IQR] 0.7 [0.6 to 1] vs. 1 [0.6 to 1.5] mg, P < 0.007) and had lower pain scores during the first 60 min after surgery. There were no statistically significant differences in postoperative nausea and vomiting incidence, need for antiemetics or complications. CONCLUSION: Compared with peritonsillar infiltration, preemptive intravenous tramadol decreases the need for postoperative opioids after tonsillectomy in children without increasing the incidence of side effects. TRIAL REGISTRATION: EudraCT 2011-005467-25.

A randomized, single-blind, prospective trial of auricular 'battlefield' acupuncture for the reduction of postoperative tonsillectomy pain in adults.

AIM: The purpose of this randomized, single-blind trial was to evaluate the efficacy of battlefield acupuncture in reducing postoperative pain and opioid consumption after adult tonsillectomy. METHODS: Adult participants undergoing a tonsillectomy were randomized to either receive auricular 'battlefield' acupuncture or not. Groups were compared using the Wilcox rank sum test, Fisher's exact test and a generalized estimating equations model for post-discharge pain scores. RESULTS: Statistically significant difference was not noted for morphine equivalent opioid use, nor was there any difference noted in the pain scores between the control group and treatment group. CONCLUSION: Acupuncture is cheap, safe and effective in many settings. Peri-operative battlefield auricular acupuncture did not reduce postoperative pain or opioid consumption in this study.

Risks and benefits of local anesthesia versus general anesthesia in tonsillectomy.

PURPOSE: Tonsillectomy is one of the most common surgical procedures in otorhinolaryngology. Modern general anesthetic techniques have reduced surgical risks, but performing the procedure under local anesthesia may still offer significant benefit for both the patient and surgeon. This study analyzed the risks and benefits of performing tonsillectomies under local anesthesia. METHODS: This is a retrospective longitudinal cohort study analyzing postoperative bleeding rates as a primary outcome measure. Secondary outcome measures were duration of surgery, consumption of analgesics and total surgery cost. RESULTS: The study enrolled 1112 patients undergoing tonsillectomy, with 462 (41.5%) patients treated under general and 650 (58.5%) patients treated under local anesthesia. There were 12 postoperative bleeding incidents in in the local anesthesia group and 9 cases of postoperative bleeding in the general anesthesia group. No significant differences based on gender regarding quantity of intraoperative bleeding or patient age were observed between the patients undergoing local versus general anesthesia. However, significant differences were noted between the groups in analgesic consumption, (Mann-Whitney U test, p = 0.001), duration of operating room stay (Mann-Whitney U test, p = 0.001), duration of surgery (Mann-Whitney U test, p = 0.001) and cost of surgery (Mann-Whitney U test, p = 0.001). CONCLUSIONS: The incidence of postoperative bleeding is not dependent on type of anesthesia. The results suggest that tonsillectomy performed under local anesthesia is a safe alternative to tonsillectomy under general anesthesia, with significant reduction of cost and duration of surgery.

Treating pediatric post-tonsillectomy pain and nausea with complementary and alternative medicine.

OBJECTIVES: Although tonsillectomy is a common and largely safe procedure, pain management in children remains a controversial topic. In addition to the challenge of choosing appropriate analgesia, there is often low parent and child adherence. This article presents a review, and evaluates the potential role, of a range of complementary and alternative therapies that may be sought out by parents. METHODS: A literature review of complementary and alternative interventions performed using PubMed, Cochrane Library, and EMBASE, supplemented by searches from Google and hand searches of cross-references of selected articles, yielded 32 studies for qualitative analysis. RESULTS: The studies included for analysis investigated a wide variety of alternative treatment modalities: acupuncture and related therapies, aromatherapy, homeopathy, honey, intravenous fluid, speech therapy, hyaluronic acid, behavioral therapies, ice/cold, hydrogen peroxide rinse, and chewing gum. CONCLUSION: At this time, stronger conclusions cannot be made about the therapies investigated because there are many methodology limitations of the studies analyzed. However, our results suggest merit for these treatments as adjuvant therapies that can enhance analgesia and decrease requirements of controversial medications. Honey and acupuncture have the greatest amount of evidence for postoperative pain and nausea; however, all interventions examined were cost-effective and safe. We recommend against hydrogen peroxide rinses and chewing gum. Laryngoscope, 2625-2634, 2018.

Postoperative care after tonsillectomy: what's the evidence?

PURPOSE OF REVIEW: The purpose of this review is to evaluate the current literature regarding postoperative management after tonsillectomy in children. RECENT FINDINGS: Controversy remains regarding the ideal medication regimen to manage pain after tonsillectomy. Acetaminophen and ibuprofen are routinely used, although concerns of more severe postoperative hemorrhage with ibuprofen remain. Narcotics are prescribed commonly, but with extreme caution in children with severe obstructive sleep apnea. Although not always utilized by the authors, additional adjunctive medications such as perioperative dexamethasone, ketamine, and local infiltration of lidocaine into tonsillar pillars may decrease postoperative pain. Systematic reviews have shown that dexamethasone does not increase risk of posttonsillectomy bleeding. SUMMARY: Adenotonsillectomy is one of the most common procedures performed on children and may have significant morbidity from postoperative pain and bleeding. Managing pain remains challenging and the optimal treatment regimen has not been definitively identified. Many medications and alternative therapies have been studied and suggest possible benefit.

Comparison of topical ropivacaine with and without ketamine on post-surgical pain in children undergoing tonsillectomy: a randomized controlled double-blind study.

PURPOSE: Tonsillectomy in pediatric patients may cause severe postoperative pain. Topical local anesthetics are an easy and safe way to control post-tonsillectomy pain, but there is no benefit during the early postoperative stage. Topical ketamine shows a good effect on early stage postoperative pain. We compared the effect of topical ropivacaine with and without ketamine on post-tonsillectomy pain. METHODS: Patients aged 3-7 years undergoing tonsillectomy were selected to participate in the study. Our study was performed in a randomized, placebo-controlled, double-blind manner. Patients were randomly assigned to one of two groups using computer-generated random numbers. The researchers who assessed the pain score, the caregivers, and the patient were blinded to group assignment. One group received topical ropivacaine with saline (RS group) and the other group received topical ropivacaine with 20 mg ketamine (RK group) on the tonsillar bed. Pain scores using the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) at 15 min and 30 min, and at 1, 2, 4, 8, 16 and 24 h were recorded. Rescue analgesic requirement and complications were also recorded. RESULTS: A total of 66 patients were randomly assigned to the RS group (n = 33) and the RK group (n = 33). The mCHEOPS scores were significantly lower in the RK group at 15 min (P = 0.046). The mCHEOPS scores of the two groups decreased with time, but there was no intergroup interaction. The RS group received more analgesics until 1 h after surgery and the RK group received more analgesics during 1-24 h after surgery. There were no differences in adverse outcomes. CONCLUSIONS: Topical ropivacaine with ketamine can reduce immediate postoperative pain and analgesic requirement better than ropivacaine alone.

Codeine and opioid metabolism: implications and alternatives for pediatric pain management.

PURPOSE OF REVIEW: Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. RECENT FINDINGS: Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY: Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative pain management is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety.

[Acupuncture in posttonsillectomy pain : A prospective double-blind randomized controlled trial. German version]. / Einsatz von Akupunktur bei Posttonsillektomieschmerz : Eine prospektive, randomisierte und kontrollierte Doppelblindstudie.

BACKGROUND: Postoperative swallowing pain is one of the most unpleasant after-effects of tonsillectomy. During recent years, the demand for alternatives to drug-based pain therapy has continued to grow, although the topic has received little research attention until now. MATERIALS AND METHODS: A total of 46 patients were randomized into verum acupuncture, control acupuncture, and drug-based treatment groups. All patients received nonsteroidal antirheumatic drugs (NSAIDs). One hour after drug intake, the verum group also received acupuncture according to classical acupuncture rules (S34, S44 and PC5). The control group had acupuncture needles placed at nonspecific acupuncture points in the midaxillary line. Acupuncture was performed by a blinded acupuncturist, who had learnt exclusively these techniques in the run up to the study. Patients were asked to evaluate their pain before, and at intervals of 20 min, 1 h, 2 h, and 3 h after drug intake/acupuncture treatment using a visual analog scale (VAS). RESULTS: The analgesic effect of acupuncture was significant up to 3 hours in the verum group (p < 0.05). The analgesic effect in the control acupuncture group was significant for up to 1 h after acupuncture (p < 0.05). With reference to the time point before acupuncture, the differences between both acupuncture groups and the drug group were significant (p < 0.01) over the whole time. CONCLUSION: Acupuncture is an effective complement to NSAIDs in the treatment of posttonsillectomy pain. Particularly patients with allergies, drug intolerance, or reduced response to the commonly administered drugs may benefit from acupuncture.

The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: A randomized double-blind clinical trial.

BACKGROUND: Local anesthetic infiltration and corticosteroids had shown effectiveness in reducing post tonsillectomy nausea, vomiting and pain. OBJECTIVES: To compare the effect of intravenous dexamethasone versus pre-incision infiltration of local anesthesia in pediatric tonsillectomy on postoperative nausea and vomiting (PONV). The secondary objective was postoperative pain. METHODS: A randomized double-blind clinical trial was conducted at a tertiary care teaching hospital. Children admitted to undergo tonsillectomy aged between 4 and 13 years from January 2015 to August 2015 were enrolled and divided into two groups. Both groups had general anesthesia. Group I received intravenous dexamethasone 0.5 mg/kg (maximum dose 16 mg) with placebo pre-incision infiltration. Group II received pre-incision infiltration a total of 2-4 ml local anesthesia mixture with saline and an equivalent volume of intravenous saline. RESULTS: Group I consisted of 64 patients while group II had 65 patients. In the PACU, 15.6% of patients in group I experienced vomiting compared to 3.1% in group II (p-value = 0.032). After 24 h, the incidence of PONV was significantly higher in group I compared to group II (26.6% vs. 9.2% respectively, p-value = 0.019). At 48 h postoperatively, PONV was significantly higher in group I (p-value = 0.013). The incidence was similar in both groups after three, four and five postoperative days. Baseline pain and pain during swallowing were significantly different at 6, 12 and 24 h as well as days 1 through 5. Pain upon jaw opening was significantly different at 6, 12 and 24 h between the two groups. Pain while eating soft food was significantly different at 24 h and days 2 through 5. In the PACU, 20.3% of patients in group I received diclofenac compared to 3.1% in group II (p-value = 0.005). From day 1 till day 5, analgesic consumption was significantly higher in group I. CONCLUSION: Local anesthetic infiltration in addition to NSAIDS and paracetamol could serve as a multimodal analgesia and decrease PONV. TRIAL REGISTRATION: NCT02355678.

Clinical practice guideline: tonsillitis II. Surgical management.

In 2013, a total of 84,332 patients had undergone extracapsular tonsillectomies (TE) and 11,493 a tonsillotomy (TT) procedure in Germany. While the latter is increasingly performed, the number of the former is continually decreasing. However, a constant number of approximately 12,000 surgical procedures in terms of abscess-tonsillectomies or incision and drainage are annually performed in Germany to treat patients with a peritonsillar abscess. The purpose of this part of the clinical guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through the surgical treatment options to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical treatment options encompass intracapsular as well as extracapsular tonsil surgery and are related to three distinct entities: recurrent episodes of (1) acute tonsillitis, (2) peritonsillar abscess and (3) infectious mononucleosis. Conservative management of these entities is subject of part I of this guideline. (1) The quality of evidence for TE to resolve recurrent episodes of tonsillitis is moderate for children and low for adults. Conclusions concerning the efficacy of TE on the number of sore throat episodes per year are limited to 12 postoperative months in children and 5-6 months in adults. The impact of TE on the number of sore throat episodes per year in children is modest. Due to the heterogeneity of data, no firm conclusions on the effectiveness of TE in adults can be drawn. There is still an urgent need for further research to reliably estimate the value of TE compared to non-surgical therapy of tonsillitis/tonsillo-pharyngitis. The impact of TE on quality of life is considered as being positive, but further research is mandatory to establish appropriate inventories and standardized evaluation procedures, especially in children. In contrast to TE, TT or comparable procedures are characterized by a substantially lower postoperative morbidity in terms of pain and bleeding. Although tonsillar tissue remains along the capsule, the outcome appears not to differ from TE, at least in the pediatric population and young adults. Age and a history of tonsillitis are not a contraindication, abscess formation in the tonsillar remnants is an extremely rare finding. The volume of the tonsils should be graded according to Brodsky and a grade >1 is considered to be eligible for TT. The number of episodes during 12 months prior to presentation is crucial to indicate either TE or TT. While surgery is not indicated in patients with less than three episodes, a wait-and-see policy for 6 months is justified to include the potential of a spontaneous healing before surgery is considered. Six or more episodes appear to justify tonsil surgery. (2) Needle aspiration, incision and drainage, and abscess tonsillectomy are effective methods to treat patients with peritonsillar abscess. Compliance and ability of the patient to cooperate must be taken into account when choosing the surgical method. Simultaneous antibiotic therapy is recommended but still subject of scientific research. Abscess tonsillectomy should be preferred, if complications have occurred or if alternative therapeutic procedures had failed. Simultaneous TE of the contralateral side should only be performed when criteria for elective TE are matched or in cases of bilateral peritonsillar abscess. Needle aspiration or incision and drainage should be preferred if co-morbidities exist or an increased surgical risk or coagulation disorders are present. Recurrences of peritonsillar abscesses after needle aspiration or incision and drainage are rare. Interval TE should not be performed, the approach is not supported by contemporary clinical studies. (3) In patients with infectious mononucleosis TE should not be performed as a routine procedure for symptom control. TE is indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia. If signs of a concomitant bacterial infection are not present, antibiotics should not be applied. Steroids may be administered for symptom relief.

The effect of acupuncture on postoperative nausea and vomiting after pediatric tonsillectomy: A meta-analysis and systematic review.

OBJECTIVES/HYPOTHESIS: Tonsillectomy is one of the most frequently performed pediatric surgical procedures worldwide. The complications of this procedure include postoperative nausea and vomiting (PONV) and pain; therefore, both the treatment and prevention of PONV are important. Classical antiemetics include drug therapies such as ondansetron, which are undesirable because they often carry a high cost and several side effects. Therefore, in this study we aimed to evaluate the antiemetic effect of acupuncture after pediatric tonsillectomy. METHODS: We searched for eligible articles that reported on the antiemetic effects of acupuncture after tonsillectomy using the three databases, MEDLINE, Embase, and Cochrane, through July 2015. We included full-length original articles with adequate data for evaluating the antiemetic effects on pediatric tonsillectomy in the form of a relative ratio. The Newcastle-Ottawa scale was used to assess the quality of case control and cohort studies, and the Cochrane risk of bias tool was employed for randomized controlled trials (RCTs). RESULTS: The search identified 415 publications. After screening, we selected eight articles for review (4 RCTs, 3 prospective cohorts, and 1 pilot study). A meta-analysis of acupuncture in pediatric tonsillectomy revealed that the number of patients with PONV was significantly reduced with acupuncture compared to the control group, with a risk ratio of 0.77 (95% confidence interval: 0.63-0.94, P < 0.05). CONCLUSION: When acupuncture at PC6 (neiguan) was used to prevent PONV after pediatric tonsillectomy, the risk ratio was significantly lower compared to that of conventional drug therapy. Although further randomized controlled trials are needed, acupuncture at PC6 is considered an economic and effective treatment for emesis after pediatric tonsillectomy. Laryngoscope, 126:1761-1767, 2016.