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Dr. Nemer Al-Khtoum, MD* department of otolaryngology, royal medical services.
Amman - Jordan.
Abstract
Objective: to compare the efficacy of pre-operative local infiltration
of local anesthetic (bupivacaine) with the conventional parenteral administration
of an NSAID, diclofenac sodium on postoperative pain in adults undergoing tonsillectomy
using a standardized anesthetic technique.
Patients and Methods: 120 patients of either sex, age 20 to 40 years
posted for tonsillectomy were enrolled and randomly assigned into 2 groups:
Group A: Received diclofenac sodium 1.5 mg/kg intramuscular, 30 min. before
surgery (60 patients).
Group B: Received bilateral pre-incisional infiltration of 3 ml of 0.25% bupivacaine
in the peritonsillar fossa (60 patients).
Results: Pain intensity after surgery was assessed by asking patients
to express there pain on visual analogue scale 0- 100 mm scale ( 0 mm: no pain;
100 mm : maximum imaginable pain) and estimated at 1 hour, 3 hours, 6 hours,
12 hours and 24 hours after surgery.
There was no statistically significant difference between group A and B at all
time intervals (p< 0.01).
Conclusion: preincisional infiltration of local anesthetic (bupivacaine)
and pre-operative parenteral administration of an NSAID, diclofenac sodium were
found to be equally effective methods for treating post tonsillectomy pain.
INTRODUCTION
Tonsillectomy is one of the most frequently performed ambulatory surgical procedures.1The
introduction of an electrodissection surgical technique has virtually eliminated
immediate postoperative hemorrhage. However, it may cause more pain, discomfort
and poor oral intake due to more local inflammation, nerve irritation and laryngeal
muscle spasm.2 Pain is still the most significant obstacle to the rehabilitation
of a patient following tonsillectomy.
Post tonsillectomy pain has maximum intensity immediately after operation and
in the first three post operative days.3 Thus there is a need to achieve adequate
pain control, various strategies for the management of post tonsillectomy pain
have been proposed like infiltration of local anaesthetic,4,5non-steroidal anti-inflammatory
drugs (NSAID)6, narcotics and oral analgesics7. Application of sucralfate as
a protective barrier following tonsillectomy has been found to promote healing
with significant pain reduction in the post-operative period.8
The aim of this study was to compare the efficacy of pre-operative local infiltration
of local anesthetic (bupivacaine) with the conventional parenteral administration
of an NSAID, diclofenac sodium on postoperative pain in adults undergoing tonsillectomy
using a standardized anesthetic technique.
MATERIALS AND METHODS
This study was conducted in the Department of Otorhinolaryngology, Royal medical
services, Jordan, in the period from June 2003 to July 2005.
After an informed written individual consent was taken, 120 patients of either
sex, age 20 to 40 years posted for tonsillectomy were enrolled the indication
being chronic tonsillitis, recurrent episodes of acute tonsillitis.
Cases of peritonsillitis, peritonsillar abscess, neoplastic lesions, patients
with a known allergy to the drugs being used, asthma, kidney, or hepatic dysfunction
or hemorrhagic diathesis were excluded.
Patients were randomly assigned to each group using a list of random numbers,
and received either of the two treatment modalities.
Group A: Received diclofenac sodium 1.5 mg/kg intramuscular, 30 min. before
surgery (60 patients).
Group B: Received bilateral pre-incisional infiltration of 3 ml of 0.25% bupivacaine
in the peritonsillar fossa (60 patients).
All the tonsillectomies were performed using a standardized anesthetic technique.
By one surgeon employing the blunt dissection technique (Boyle-Davies). The
bleeding was controlled by bipolar diathermy or ligation.
Pain was estimated in all patients by an independent observer. Visual analogue
score (VAS) was assessed on a 0- 100 mm scale ( 0 mm: no pain; 100 mm : maximum
imaginable pain) and estimated at 1 hour, 3 hours, 6 hours, 12 hours and 24
hours after surgery.
RESULTS
There was no significant difference in demographic data between the two groups.
The mean post-operative pain scores for group A at 1 hour, 3 hours, 6 hours,
12 hours and 24 hours after surgery were (26.25±6.66, 32.00±5.47,
30.50±4.84, 14.25±4.37, 9.5±1.53) respectively.
The mean post-operative pain scores for group B at 1 hour, 3 hours, 6 hours,
12 hours and 24 hours after surgery were (28.50±4.89, 32.00±4.47,
30.57±4.84, 17.25±5.97, 8.7±1.37) respectively.
There was no statistically significant difference between group A and B at all
time intervals (p< 0.01).
DISCUSSION
The reduction of post-tonsillectomy pain is important not only for the patient
comfort, but also because reducing pain improves oral intake, reduces the risk
of dehydration, infection and post surgery hemorrhage. 9
Throat pain, referred otalgia and bleeding after tonsillectomy contribute to
making recuperation difficult and prolonged. Therefore adequate analgesia is
necessary to relieve the agony of pain and reduce incidence of bleeding since
increased vascular congestion of the head and neck associated with crying may
precipitate bleeding10.The most common method of providing postoperative analgesia
is systemic administration of narcotic analgesics though these drugs have their
own side effects.
Post tonsillectomy pain is probably the result of muscle spasm caused by inflammation
and irritation of the pharyngeal musculature. 8
Bupivacaine is an amide- linked local analgesic. It was synthesized by Ekenstan
in 1957 and has been used extensively in obstetric practice to produce epidural
analgesia and peripheral nerve blockade in the management of intractable pain.
It's high lipid solubility and protein binding results in rapid onset of action
and prolonged duration (6-9 hours). The recommended upper limit of safe dosage
of bupivacaine is 2mg/kg body weight.11Systemic toxicity produces arrhythmia,
drowsiness, convulsions, paraesthesia, disorientation and nystagmus.
Diclofenac sodium 1 mg/kg intramuscular, given after induction of anaesthesia
was found to be an effective alternative to opiates in tonsillectomy patients.
7
During surgery, pain impulses entering the central nervous system, create a
hyperexcitable state inspite of general anaesthesia. Blockade of these impulses
by preoperative analgesic drugs12 or infiltration of local anaesthetic agents
has a pre-emptive analgesic effect.4 Therefore we planned to give parenteral
diclofenac and local infiltration before the tissue trauma.
Conclusion
Our results showed that Preoperative diclofenac in group A and preincisional
infiltration in group B were found to be equally effective methods for treating
post tonsillectomy pain.
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10. Hannington —
Kiff JG : The need for analgesic cover after ENT surgery — comparison
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*Correspondence should be addressed to:
DR. Nemer Al- Khtoum.
Department of ENT. RMS. Jordan Armed Forces.
Amman- Jordan
PO Box – Sweileh 1834
Email;nemer72@gmail.com
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First Published 23-Sep-2005 3:21 PM