CAUSES OF POST TONSILLECTOMY PAIN AND HOW TO AVOID

1. Postoperative Pain In
Tonsillectomy
Mohamed Abaza
Otorhinolaryngology- H&N Surgery

2. Introduction
Tonsillectomy and adenoidectomy is one of the most
common pediatric surgical procedures and is well
known to be associated with significant postoperative
pain
In 1994 140,000 U.S. children under the age of 15 had
adenoidectomies and 286,000 had
adenotonsillectomies

3. “Pain-free” tonsillectomy
Certain methods are associated
with less post-operative pain
Are these methods also associated
with increased bleeding or other
risks?

4. “Old Methods”
Cold Knife
Electrocautery

5. “New Methods”
Coblation
Harmonic scapel
Ligasure (Thermal Welding)
Laser
Intra-capsular methods

6. Cold Knife
Still the “Gold Standard”
Trade high
intraoperative blood loss
for less post-operative
pain
Post tonsillectomy
hemorrhage (PTH)
probably less common
than electrocautery
Inexpensive

7. Electrocautery: Monopolar & Bipolar
Monopolar cautery is
currently the most common
method of tonsillectomy in
the United States
Bipolar cautery has is
commonly used
internationally
Suction cautery has also
been described but is not
extensively used

8. Electrocautery Principles
The post-operative pain associated with cautery is
attributed to the spread of thermal injury
Using cut or blend instead of coag may decrease
post-operative pain (good study needed here)

9. Electrocautery: Monopolar & Bipolar
Low intraoperative
blood loss
Possibly higher PTH
rates than cold knife
Highest pain

10. Coblation
Uses radiofrequency (RF) energy to ionize NaCl in a
saline medium, then the energy of these ions
(plasma) is used to break molecular tissue bonds
May also be used for direct hemostasis
RF energy is supposed to stay in the irrigation to
minimize collateral heating
Temperatue is not supposed to exceed 70 C
(cautery is routinely 200-400 C)

11. Coblation-Advantages
Less pain than electrocautery, some cite equivalent
pain to cold knife
Intraoperative blood loss comparable to
electrocautery
No electrical connection to patient
Coblation-Disadvantages
Very high cost compared to electrocautery or cold knife
PTH seem to be equivalent to electrocautery or may even
be higher
Operative times up to twice as long than electrocautery
Aggressive marketing campaign targeted to lay public

12. Coblation-Post Op Pain
Stoker et al, Otolaryngol Head Neck Surg
204; 130: 666-75

13. Harmonic Scalpel
Blade vibrates at 55,500 hertz
This vibration is in the RF range and causes
proteins to denature and form a coagulum which
seals small vessels and divides tissue
Larger vessels can be sealed by continuous contact
and secondary heating

14. Harmonic Scalpel-Advantages
Lower post-operative pain than electrocautery
Intraoperative blood loss comparable to
electrocautery
Possibly lower PTH rates than electrocautery
No electrical connection to patient
Harmonic Scalpel-Disadvantages
Expensive
Longer operative time than electrocautery or cold
knife

15. Thermal Welding
 Variation of bipolar cautery and bipolar scissors
 Feedback system to automatically control ‘seal cycle’
 Minimizes thermal spread
 Rated for up to 7 mm vessels at 3x normal SBP
 ‘Melts’ collagen and elastin to form a coagulum similar to plasma and
harmonic scalpel
 Does not rely of proximal thrombus like standard electrocautery
 Also used for neck surgery and thyroid surgery
 May eventually replace standard bipolar

16. Thermal Welding-Advantages
Less post operative pain than monopolar
electrocautery
Cost is less than Coblation and Harmonic scalpel
Thermal Welding-Disadvantages
Very new
PTH rates unknown
Still more costly that monopolar and cold knife

17. Laser
Used for debridement of
hypertrophied tonsils
Several laser types used
Typically leaves 10-25%
of tonsil tissue behind
Associated with lower
post-operative pain than
electrocautery

18. Adjuvant Therapies
Aims are to reduce comorbidities of
tonsillectomy
1. Reduce pain
2. Reduce nausea
3. Resume diet
4. Resume activity
5. Reduce overall postoperative cost

19. Adjuvant Therapies
Basic catagories
Operative hemostasis (afrin)
Local Anesthetic: Bupivacaine
Perioperative Steroids: Dexamethasone
Postoperative Antibiotics
Post operative pain control

20. Perioperative Steroids
No adverse effects with one dose of perioperative
steroids.
Reduction in post operative pain levels and 24 hr
emesis rates
Dose range from 0.1-1.0 mg/kg up to a total dose
of 50 mg

21. Post Operative Antibiotics
Now generally accepted in the literature as
routine
Some disagreement on type and duration
Most studies recommend a 5-7 day course of
narrow spectum (amoxicillin) antibiotics
Thought to decrease post operative pain and post
operative healing time by decreasing the bacterial
oral flora

22. Postoperative Antibiotics
Decrease bacterial colonization of pharyngeal
tissues to reduce inflammation following
tonsillectomy
Pain reduction
Improving oral intake
Possibly decreasing postoperative bleeding
Controversial: Bacterial Resistance

23. Local Anesthetics
Three major catagories
Pre-surgical injection
Post-surgical injection
Topical administration post operatively

24. Local Anesthetic
Tonsils innervated by:
Tonsillar branches of glossopharyngeal nerve
Palatine nerves of V2
Lingual branches of V3
Bupivacaine: amide anesthetic
High lipid solubility and protein binding
Rapid onset with effect lasting 6-9 hours

25. Post Operative Pain Control
 Tylenol
 Narcotics (and tylenol/narcotic combonations)
 NSAIDS

26. Post Operative Pain Control
Opioids
 Mainstay of postop analgesia
 Increase incidence of postop emesis & respiratory morbidity
Paracetamol (Oral/ Rectal/ I.V.)
 Plain Tylenol may be sufficient in young pts
 NSAIDS
 (great controversy / bleeding vs pain)
 safe and effective and reduce narcotic complications without increasing
bleeding.

27. No Codeine After Tonsillectomy
 The FDA reports that deaths have occurred after surgery in
children with OSAS who received codeine for pain relief following
such surgeries.
 Some children are “ultra-rapid metabolizers” of codeine, meaning
that their liver converts codeine to morphine in higher than normal
amounts. “High levels of morphine can result in breathing difficulty,
which may be fatal,” the FDA warns.