Airidas Brazlauskas1
1 Faculty of Medicine, Vilnius University, Vilnius, Lithuania
Abstract
Tonsillectomy is one of the most frequently performed surgeries by otorhinolaryngologists globally. When performed with proper indications, tonsillectomies provide long-term improvements in health and quality of life. It is different from other surgical procedures because the wounds are left open to heal by secondary intention, thus the main complaint from patients after the surgery is severe pain. None of the modern surgery techniques stand out as superior when comparing their post-surgery pain levels. A wide variety of studies have been conducted where different types of pain-relieving medications were compared, however, to this day, there are no clear pain management guidelines after tonsillectomies. Acetaminophen and ibuprofen provide only a moderate relief of pain. Dexamethasone, when used in multimodal treatment, provides higher analgesia than the monotherapy of nonsteroid anti-inflammatory drugs. The research on opioid analgesics is very limited, yet available studies show, that it bestows excellent pain relief for patients after the removal of palatine tonsils with little to no adverse effects. Further research is needed to determine the most optimal course of action, providing an adequate pain management method for patients after tonsillectomies.
Keywords: postoperative pain management, tonsillectomy, surgical technique, pain medication.
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Medical Sciences 2020 Vol. 8 (17), p. 239-245
Postoperative pain management after tonsillectomy: a literature
review
Airidas Brazlauskas
1
1
Faculty of Medicine, Vilnius University, Vilnius, Lithuania
Abstract
Tonsillectomy is one of the most frequently performed surgeries by otorhinolaryngologists globally. When
performed with proper indications, tonsillectomies provide long-term improvements in health and quality of
life. It is different from other surgical procedures because the wounds are left open to heal by secondary
intention, thus the main complaint from patients after the surgery is severe pain. None of the modern surgery
techniques stand out as superior when comparing their post-surgery pain levels. A wide variety of studies have
been conducted where different types of pain-relieving medications were compared, however, to this day, there
are no clear pain management guidelines after tonsillectomies. Acetaminophen and ibuprofen provide only a
moderate relief of pain. Dexamethasone, when used in multimodal treatment, provides higher analgesia than
the monotherapy of nonsteroid anti-inflammatory drugs. The research on opioid analgesics is very limited, yet
available studies show, that it bestows excellent pain relief for patients after the removal of palatine tonsils with
little to no adverse effects. Further research is needed to determine the most optimal course of action, providing
an adequate pain management method for patients after tonsillectomies.
Keywords: postoperative pain management, tonsillectomy, surgical technique, pain medication.
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240
Introduction
Although the necessity for tonsillectomies has
reduced after the discovery of antibacterial
treatment, however. it remains one of the most
common surgical procedures performed by
otorhinolaryngologists. Tonsillectomies are
performed more than 400 000 times in the
European Union each year (1). Historical archives,
describing the procedure, date back a thousand
years before Christ in India (2). Over the years,
technological advancements in medicine had a
large impact on tonsillectomies, as new and more
advanced instruments had been invented, the
surgical technique had been improved and general
anesthesia started being used during surgeries.
Sadly, the removal of tonsils is still a very
controversial procedure, simply because, despite
being a relatively simple technique, it remains
dreadfully unpleasant for patients and presents a
considerably large amount of complications (3).
Severe pain is the most common complaint, during
the postoperative period (4). Most patients report
this pain to be similar to the one experienced during
acute tonsillitis (5). Studies confirm, that analgesia
after the surgery is not sufficient enough, however,
there is no worldwide consensus on what the most
optimal pain management approach should be (6).
Indications for tonsillectomy
Due to the adequate use of antibacterial treatment,
the rates of tonsillectomies had been reduced,
however, it remains a commonly performed
procedure in both adults and children (7). Studies
show that, when performed with the proper
indications, tonsillectomies are associated with
long-term improvements in health, quality of life,
and lower utilization of medical resources (1).
Authors mainly name these following indications
for surgical treatment:
• Recurrent tonsillitis;
• Peritonsillar abscess;
• Tonsil hyperplasia causing obstructive
sleep apnoea symptoms;
• Suspected tonsillar malignancy (8).
Tonsillectomies, in general, are different from
other surgical procedures, because unlike other
surgeries, wounds, after the removal of palatine
tonsils, are left unsutured to heal by secondary
intention (7). For this reason, patients experience
severe pain after surgery. The pain is the result of
the disruption of mucosa and glossopharyngeal and
vagal nerve fiber irritation followed by
inflammation and spasm of the pharyngeal muscles
that leads to ischemia and a protracted cycle of pain
(5). Some studies claim, that patients with recurrent
tonsillitis qualified for tonsillectomy, experience
less pain than those, who were treated surgically
for other indications (9). However, the evidence is
scarce and further research should be conducted to
form a valid conclusion.
Surgery techniques and postoperative pain
Several techniques have been described in
literature to reduce morbidity and enhance
recovery post-surgery. The most common surgical
techniques for tonsillectomies are cold dissection,
also known as traditional tonsillectomy,
monopolar-bipolar diathermy dissection, harmonic
scalpel tonsillectomy, and coblation dissection (5).
Postoperative pain and hemorrhage are the most
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241
important focuses when comparing different
techniques.
Cold dissection is one of the oldest
methods for performing tonsillectomies. This
technique has been used for over a hundred years
(2). During the procedure, the palatine tonsil and
capsule are dissected from surrounding tissue using
a scalpel or scissors. The inferior pole is then
amputated with a snare. Many studies are
comparing cold dissection with other surgical
methods, however, there is no significant evidence
supporting traditional tonsillectomy over other
more modern techniques (10).
The monopolar-bipolar diathermy
dissection is the most common method used for
removing tonsils in the United States (11). The
main difference is using the electrocautery tip or a
microdissection needle to separate the tonsil along
with its capsule from surrounding tissue. It is
believed, that the thermal damage to nearby tissue
may cause more severe pain after surgery,
however, conducted research shows no significant
difference in patient-reported pain intensity
between cold dissection and electrocautery
dissection (5).
A harmonic scalpel was first used for
tonsillectomy in the year 2000 (10). The main
principle of this method is that the blade of the
instrument vibrates at 55 kHz, thus it can cun
tissues and coagulate vessels at the same time (12).
Several studies report different and somewhat
paradoxical results. When comparing the
conventional cold dissection and the harmonic
scalpel methods, patients experienced better
outcomes in terms of intraoperative bleeding and
pain on the first postoperative day, however, there
were no significant differences in other parameters,
such as late postoperative bleeding and pain on the
seventh postoperative day (5,10). Furthermore, the
harmonic scalpel does not provide any major
benefits over more conventional methods of
tonsillectomy and is equivalent to electrocautery in
postoperative pain outcomes (13). Moreover, the
cost of surgery is higher when using the harmonic
scalpel (12).
Coblation dissection is a relatively new
method used for tonsillectomies. The main
principle in this technique is that a radiofrequency
bipolar electrical current is sent through a medium
of normal saline, which results in a plasma field of
highly ionized particles that break molecular bands
between cells (14). This enables the ablation of
tonsils at much lower temperatures than
electrocautery dissection (15). Thus, it is believed
to cause less damage to surrounding tissue. Studies
show varying results when comparing coblation
with other tonsillectomy techniques. Several
authors claim that coblation tonsillectomy caused
significantly less pain when compared with
conventional techniques (16,17). Others, however
found no significant difference in postoperative
pain levels between different techniques (5).
Many new tonsillectomy techniques have
been developed over the years and many studies
have been performed comparing them, however,
the results between them are varying and
inconclusive. None of these surgical methods have
been chosen as the best technique worldwide. It is
necessary to conduct further research, to determine
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which tonsillectomy technique provides the lowest
level of pain post-surgery.
Medication for pain management
The main postoperative complaint is severe pain.
Intense pain lasts several days and gradually
reduces over the course of two weeks after
tonsillectomy, thus the use of analgesics is highly
recommended (6). Many studies are comparing
several drugs and their combinations, however,
there are no clear guidelines that would dictate the
most optimal postoperative pain management after
tonsillectomies. The most commonly used pain
relief methods involve acetaminophen,
nonsteroidal anti-inflammatory drugs,
glucocorticoids, and opioid medication for pain.
Acetaminophen is one of the most widely
used medicines worldwide. It exhibits clinically
proven antipyretic and analgesic properties similar
to nonsteroidal anti-inflammatory drugs (18).
However, unlike NSAIDs, acetaminophen is a
weak cyclooxygenase inhibitor, thus it has a weak
anti-inflammatory effect, minimal gastrointestinal
side effects, and has a small dose-dependent effect
on thrombocyte function (18). On the other hand,
nonsteroidal anti-inflammatory drugs, such as
ibuprofen, have a higher effect on inflammation,
but also a higher effect on platelet function,
therefore it may lead to a higher risk of
postoperative bleeding (19). Several studies have
compared acetaminophen and ibuprofen, using the
Visual Analogue Scale for measuring pain intensity
after tonsillectomies. The authors found no
significant difference in pain relief between the two
medications, both provided adequate postoperative
analgesia (6). Other reports claim that ibuprofen
provides better analgesia after surgery, but is
associated with a higher risk of post-tonsillectomy
hemorrhage (20). Therefore, having such diverse
results in various studies, it is unclear which
treatment approach would be optimal.
A single intraoperative dose of
dexamethasone is known to reduce nausea and the
risk of vomiting post-surgery (21). While
conducting research, the authors noticed better pain
management outcomes in patients that received
dexamethasone during the procedure (21). Thus,
further investigation was necessary to confirm
glucocorticoid pain relief properties. Several
studies analysed the effects of dexamethasone for
patients after tonsillectomies. Because of the high
post-tonsillectomy pain intensity, the analgesic
effect did not reach clinical meaningfulness when
dexamethasone was used alone, however, when
included in multimodal treatment along with
NSAIDs or acetaminophen, moderate pain relief
effects have been achieved (22). Intraoperative
dexamethasone usage is not related to a higher risk
of post-tonsillectomy hemorrhage and no other
adverse effects have been reported (21,22). Further
research is needed to identify the best possible
combination of medicine for optimal pain
management.
There is not enough information to fully
support the effective pain relief properties of opioid
analgesics. Due to the opioid overdose crisis in the
United States, opioid use has become stigmatized
worldwide. One study compared oxycodone and
dexamethasone as pain management options after
tonsillectomies. Authors report, that oxycodone
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significantly reduces the postoperative pain and
provides better pain relief than dexamethasone
(23). Studies report no respiratory depression
complications or other adverse effects while
administering oxycodone (23,24). Opioid
analgesics might be a safe and adequate pain
management method, however, further research is
necessary, because the available literature is very
limited.
Conclusion
Effective pain management after
tonsillectomies is a wide area for research. The
palatine tonsil removal is one of the most common
surgeries performed in otorhinolaryngology,
however, there are no clear guidelines for
postoperative pain management. Patients
experience severe pain during their recovery
process and the administered analgesia is
questionable. Many studies have been performed,
analysing several pain-relieving medications,
however, no clear consensus has been reached.
Studies suggest, that no surgery method has a clear
advantage over others in terms of lower
postoperative pain. Available literature leaves
much to be desired and further research must be
conducted to make a firm conclusion on the best
treatment approach for patients.
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