Tonsillectomy 2019

Tonsillectomy-specific evidence

Data table: Paracetamol for pain management after tonsillectomy

• Sixteen studies involving 2058 patients were included:
  • Two studies with a mixed population (Atef 2008; Salonen 2009)
  • 14 studies in children (Akça 2015; Elango 2017; Dahi-Taleghani 2011; Haddadi 2014; Hamed 2018; Jotić 2019; Kocum 2013; Merry 2013; Playne 2018; Ramirez 2015; Roberts 2018; Sutters 2010; Thung 2017; Uysal 2011)
  • Paracetamol was administered intra-operatively in 10 studies, intra-operatively and postoperatively in four studies and postoperatively only in two studies.

Arguments for…

• Two studies reported an analgesic benefit when IV paracetamol was compared with placebo (Atef 2008; Salonen 2009); pain scores (Atef 2008) and opioid consumption (Atef 2008; Salonen 2009) were lower.
• In head-to-head comparisons with NSAIDs or dexamethasone, pain scores and opioid consumption were comparable (Kocum 2013; Merry 2013).
• One study reported a weak benefit (reduction of opioid consumption) of the combination of NSAID with paracetamol vs NSAID alone (Salonen 2009).

Arguments against…

• One study demonstrated that one dose of dexamethasone had a stronger analgesic effect than one dose of paracetamol when given intra-operatively in children (Faiz 2013).

PROSPECT Recommendations

• The basic analgesic regimen should include paracetamol (Grade D) and non-steroidal anti-inflammatory drugs (NSAIDs) (Grade A) administered pre-operatively or intra-operatively and continued postoperatively.

Tonsillectomy-specific evidence

Data table: NSAIDs/COX-2-selective inhibitors for pain management after tonsillectomy

• Twenty-six studies including 2455 patients were considered for analysis. Pain was the primary outcome in all studies:
  • Eight studies in adults (Graf 2008; Ismail 2010; Mowafi 2011; Ng 2017; Nishiike 2007; Türk 2018; Daele 2016; Xie 2012)
  • Three studies with a mixed population (Kang 2017; Hanani 2019; Muderris 2016)
  • 15 studies in children (Abdel-Ghaffar 2012; Abdel-Ghaffar 2015; Bean-Lijewski 2007; Damghani Mohammad 2018; Eladl 2019; El-Fattah 2013; Hamza 2012; Hannam 2014; Lee 2009; Li 2016; Mahgoobifard 2014; Moss 2014; Murto 2015; Tan 2016; Ubale 2016).

Arguments for…

• Twenty studies supported the use of NSAIDs (Kang 2017; Abdel-Ghaffar 2012; Abdel-Ghaffar 2015; Bean-Lijewski 2007; Damghani Mohammad 2018; Eladl 2019; Graf 2008; Hamza 2012; Hannam 2014; Ismail 2010; Li 2016; Moss 2014; Mowafi 2011; Muderris 2016; Murto 2015; Nishiike 2007; Türk 2018; Ubale 2016; Daele 2016; Xie 2012).
• NSAIDs showed an opioid-sparing effect and/or a reduction in pain scores when compared with placebo (Kang 2017; Abdel-Ghaffar 2012; Abdel-Ghaffar 2015; Hannam 2014; Ismail 2010; Li 2016; Moss 2014; Mowafi 2011; Muderris 2016; Murto 2015; Daele 2016; Xie 2012).
  • In most studies showing an effect, NSAIDs were administered intravenously or orally, pre- or intra-operatively.
  • NSAIDs and COX-2-selective inhibitors showed similar efficacy.
• Three studies showed that the opioid-sparing effect was associated with a reduction in postoperative nausea and vomiting (Li 2016; Moss 2014; Hamza 2012).
• There was no evidence for increased bleeding in the included studies. Two meta-analyses published in 2013 confirmed that NSAIDs administration during tonsillectomy is not associated with an increased risk of bleeding (Lewis 2013; Riggin 2013).

PROSPECT Recommendations

• The basic analgesic regimen should include paracetamol (Grade D) and non-steroidal anti-inflammatory drugs (NSAIDs) (Grade A) administered pre-operatively or intra-operatively and continued postoperatively.

Tonsillectomy-specific evidence

Data table: Glucocorticoids for pain management after tonsillectomy

• The benefit of steroids in patients having tonsillectomy was investigated in 17 studies including 1943 patients (Aslam 2018; Attia 2018; Bhattacharya 2009; Faiz 2013; Gao 2015; Hashmi 2012; Hermans 2012; Khalili 2012; Kim 2007; Lachance 2008; Lakhan 2017; Montazeri 2009; Park 2015; Thimmasettaiah 2012; Topal 2017; Tuhanioglu 2018; Vaiman 2011).
• The majority of studies examined dexamethasone (Aslam 2018; Bhattacharya 2009; Faiz 2013; Gao 2015; Hashmi 2012; Hermans 2012; Khalili 2012; Kim 2007; Lachance 2008; Lakhan 2017; Montazeri 2009; Thimmasettaiah 2012; Topal 2017; Tuhanioglu 2018; Vaiman 2011).

Arguments for…

• Dexamethasone showed a significant analgesic effect after tonsillectomy when administered alone or in combination with other analgesics in 11 studies (Aslam 2018; Bhattacharya 2009; Faiz 2013; Gao 2015; Hashmi 2012; Hermans 2012; Lakhan 2017; Thimmasettaiah 2012; Topal 2017; Tuhanioglu 2018; Vaiman 2011).
  • There was no consistent evidence concerning the appropriate dose, or a dose-dependent effect for analgesia, but studies showing an analgesic effect in children used a dose of ≥0.15 mg.kg^–1, whereas the adult studies used a total of 8 mg or more.
• Dexamethasone consistently reduced the incidence of nausea and vomiting after tonsillectomy, being effective in low doses (2–4 mg IV).
• There was no evidence of an increased bleeding risk with dexamethasone, or other side-effects from the glucocorticoids, although none of the included studies have systematically addressed these effects. Known side-effects, such as increased blood glucose levels, increased alertness and restlessness during night, are not addressed in the studies reviewed.
• One study (Gao 2015) suggested a more relevant and sustained effect on analgesia with peritonsillar infiltration of dexamethasone instead of IV or oral administration.
• Other glucocorticoids, for example, oral prednisolone (Park 2015), seem to perform similarly, but are less studied for this purpose.
• Four recent meta-analyses on the subject draw the same conclusions (Francis 2017; Batistaki 2017; Bellis 2014; Steward 2011).

PROSPECT Recommendations

• A single dose of intravenous dexamethasone is recommended (Grade A) for its analgesic and anti-emetic effects.

Tonsillectomy-specific evidence

Data table: Gabapentinoids for pain management after tonsillectomy

• Four studies assessing oral gabapentin were included:
  • Two studies in children (Amani 2015; Amin 2011)
  • Two studies in mixed or adult populations (Jeon 2009; Sanders 2017).
• Two studies examining oral pregabalin in adults were included (Mathiesen 2011; Park 2015).

Arguments for…

• All but one study (Sanders 2017) showed an analgesic effect of gabapentinoids when compared with placebo (Jeon 2009; Park 2015) or when administered with paracetamol (Mathiesen 2011).
• There are no clear conclusions to be drawn on dosing level or whether the pre-operative dose should be repeated or not from these studies. However, data from meta-analyses report that at least 600 mg gabapentin or 150 mg pregabalin is needed in the otherwise healthy adult (Hwang 2016; Sanders 2016).

Aguments against…

• Three studies reported side-effects of gabapentinoids. Mathiesen 2011 reported more dizziness with 300 mg pregabalin.
• Gabapentinoids may cause sedation and dizziness at doses having an effect on pain scores or analgesic consumption. Tonsillectomy is a procedure associated with risks of hypoxaemia, therefore adding gabapentinoids and opioids as rescue could increase the risk of respiratory depression (Myhre 2016).
• No study included a comparison with a combined basic analgesia regimen.

PROSPECT Recommendations

• Pre-operative gabapentinoids may be considered in patients with contra-indications to the basic analgesic regimen.

Tonsillectomy-specific evidence

Data table: Alpha-2-adrenergic agonists for pain management after tonsillectomy

• Nine studies were included using alpha-2 adrenergic agonists, with 771 patients in total (Abdel-Ghaffar 2011; Abdel-Ghaffar 2019; Ali 2013; Bedirli 2017; Li 2018; Moss 2017; Mizrak 2013; Patel 2010; Sharma 2019)
  • The route of administration was either IV or by infiltrating the alpha-2-adrenergic agonist locally.

Arguments for…

• From the eight studies concerning IV dexmedetomidine in paediatric patients, four documented an analgesic effect compared with placebo (Abdel-Ghaffar 2011; Abdel-Ghaffar 2019; Li 2018; Mizrak 2013), and one compared with propofol (Ali 2013), but only for 30 min after surgery, while two studies did not show any benefit on pain scores (Bedirli 2017; Sharma 2019).
• One study compared dexmedetomidine with morphine showing an inferior analgesic effect but less respiratory depression (Zhuang 2011), and one compared with fentanyl (Patel 2010) showing improvement in analgesia with dexmedetomidine.
• Dexmedetomidine was associated with less agitation after sevoflurane-based anaesthesia in two studies (Mizrak 2013; Patel 2010).
• In a meta-analysis of dexmedetomidine for tonsillectomies, the drug came out favourably when compared with placebo or opioids in terms of postoperative pain, without any delay in post-operative care unit discharge (Cho 2018), although more sedation in the early recovery phase was reported.

Arguments against…

• None of the included studies assessed the benefit of adding dexmedetomidine on top of a basic analgesic regimen.
• Dexmedetomidine is associated with a risk of sedation, hypotension and bradycardia.
• One study documented no analgesic effect of clonidine 25 µg infiltration when a basic analgesic regimen was used (Moss 2017). There was no study assessing systemic clonidine in this setting.
• Clonidine is still included in some guidelines for analgesia after tonsillectomies in children based on efficacy in older studies (Ericsson 2015). However, these studies were mainly based on transferable results from other surgical procedures. Only two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy.

PROSPECT Recommendations

• Intra-operative dexmedetomidine may be considered in patients with contra-indications to the basic analgesic regimen.
• Clonidine is not recommended due to lack of procedure-specific evidence.

Tonsillectomy-specific evidence

Data table: Ketamine for pain management after tonsillectomy

• Nineteen studies examined systemic ketamine in paediatric patients (Abdel-Ghaffar 2019; Aydin 2007; Bameshki 2015; Taheri 2011; Dal 2007; Abdelhalim 2013; Abu-Shahwan 2008; Safavi 2012; Batra 2007; Khademi 2011; Asadi 2016; Javid 2012; Honarmand 2013; Elshammaa 2011; Eghbal 2013; Yenigun 2015; Hasnain 2012; Heidari 2012; Norouzi 2015); none of the studies included adults

Arguments for…

• Nine of ten studies comparing IV ketamine with placebo in paediatric patients showed reduced pain intensity ratings and/or reduction in opioid consumption (Dal 2007; Abdel-Ghaffar 2019; Abu-Shahwan 2008; Khademi 2011; Asadi 2016; Javid 2012; Honarmand 2013; Elshammaa 2011; Eghbal 2013).
  • One study showed no significant effects (Batra 2007).
• In one study, IV ketamine improved the analgesic effect on top of paracetamol (Asadi 2016).
  • In all other studies comparing IV ketamine with placebo, baseline analgesia was not used or not mentioned.
• One study showed significantly better analgesia with IV ketamine plus IV dexamethasone compared with placebo or both drugs alone (Safavi 2012).
• Another study showed better pain relief if IV ketamine was given pre-operatively compared with postoperatively (Aydin 2007).
• By comparing IV ketamine vs. opioids, there was significant improvement of pain scores in one study (Elshammaa 2011), reduced opioid consumption in another study (Abu-Shahwan 2008) and no difference in two studies (Taheri 2011; Abdelhalim 2013).
• One study compared IV ketamine plus midazolam with midazolam alone with only a transient effect after surgery (Bameshki 2015).
• Subcutaneous ketamine was associated with similar analgesia to the IV route (Javid 2012).
• One study evaluated the effects of peritonsillar, IV or rectal administration of ketamine in children undergoing tonsillectomy and found all were as effective as IV tramadol (Yenigun 2015).

Arguments against…

• Patients experienced more side-effects, predominantly sedation, with ketamine (Dal 2007; Honarmand 2013).
• Intramuscular ketamine did not have analgesic efficacy (Hasnain 2012).
• Oral administration was less effective compared with infiltration (Norouzi 2015).

PROSPECT Recommendations

• Intra-operative intravenous ketamine (only in children) may be considered in patients with contra-indications to the basic analgesic regimen.
  • It should be administered at the beginning of the surgical procedure as a single intravenous dose.
• Oral ketamine is not recommended due to limited procedure-specific evidence.
• Studies showed analgesic benefits of a single bolus of IV ketamine but almost all studies were done without baseline analgesia.
• Ketamine is not recommended first-line because of associated side-effects (hallucinations, agitation and sedation).
• All studies of systemic ketamine were in children; therefore, recommendations on the use of systemic ketamine for tonsillectomies were only possible for children.

Tonsillectomy-specific evidence

Data table: Magnesium sulphate for pain management after tonsillectomy

• Four studies (289 patients) examining the analgesic effect of magnesium sulphate, with pain as the primary outcome, were included:
  • Three studies in children (Abdulatif 2013; Benzon 2015; Vahabi 2012).
  • One study in adults (Tugrul 2015)

Arguments for…

• One study (Tugrul 2015) reported a reduction in pain scores when comparing oral postoperative magnesium sulphate with metamizol vs metamizol alone.
• One study (Vahabi 2012) showed a transient effect of topical magnesium sulphate vs placebo.

Arguments against…

• Two studies (Abdulatif 2013; Benzon 2015) did not show any difference when intra-operative and postoperative IV magnesium sulphate was compared with placebo.
• Among the three meta-analyses (Cho 2018; Vlok 2017; Xie 2017) included, two concluded that there was no benefit of IV administration of magnesium sulphate and two concluded that there was a small effect when administered locally.

PROSPECT Recommendations

• Magnesium sulphate is not recommended due to lack of procedure-specific evidence.

Tonsillectomy-specific evidence

Data table: Antibiotics for pain management after tonsillectomy

Arguments against…

• Eight eligible studies (Aljfout 2016; Ayala 2009; Baradaranfar 2013; Zagolski 2012; Mutiso 2011; Miura 2009; Jahanshahi 2014; Gil-Ascencio 2013) reported inconclusive pain outcomes with the use of antibiotics.
  • In studies reporting an analgesic effect, two tested antibiotic mouth wash. The analgesic effect lasted only one day and additional analgesic was still needed while the treatment was given for 3 to 7 days.
• One study reported more postoperative nausea and vomiting with the use of antibiotics (Aljfout 2016).

PROSPECT Recommendations

• Antibiotics are not recommended due to inconsistent evidence.

Tonsillectomy-specific evidence

Data table: Sucralfate for pain management after tonsillectomy

Arguments for…

• Evidence from three small studies (188 patients) suggested a weak analgesic benefit when sucralfate was used as adjuvant with repeated applications over several days (Miura 2009; Sampaio 2007; Siupsinskiene 2015).

PROSPECT Recommendations

• Sucralfate is not recommended due to limited procedure-specific evidence.

Tonsillectomy-specific evidence

Data table: Local anaesthetic infiltration or topical application for pain management after tonsillectomy

• 51 studies of local anaesthetic techniques (infiltration, topical application, spray or glossopharyngeal nerve block) were included (Aysenur 2014; Basuni 2013; Cicekci 2017; Cocelli 2012; El Daly 2019; Ergil 2012; Fikret 2011; Gemma 2009; Haksever 2014; Hong 2017; Hydri 2010; Ju 2013; Khavidaki 2015; Kilinc 2019; Naja 2017; Nikandish 2008; Oghan 2008; Ozkiris 2012; Ozmen 2011a; Ozmen 2011b; Rhendra Hardy 2010; Saki 2015; Sun 2015; Tas 2010; Teunkens 2019; Turhan 2015; Unal 2007; Yilmaz 2009; Yücel 2020; Zadeh 2016; Arikan 2008; Bayram 2015; Ghanei 2016; Kasapoglu 2013; Liang 2013; Olson 2018; Solanki 2012; Tolska 2017; Watts 2009; Gudi 2014; Inanoglu 2009; Junaid 2020; Mozafarinia 2007; Rajput 2019; Stelter 2009; Stelter 2010; Jahromi 2012; Ahmed 2019; Debasish 2019; Park 2007; Mohamed 2009).
  • 21 included comparison of bupivacaine with placebo/control (El Daly 2019; Fikret 2011; Inanoglu 2009; Junaid 2020; Mozafarinia 2007; Olson 2018; Ozkiris 2012; Ozmen 2011a; Ozmen 2011b; Rajput 2019; Unal 2007; Watts 2009; Zadeh 2016; Hydri 2010; Saki 2015; Haksever 2014; Ahmed 2019; Debasish 2019; Park 2007; Teunkens 2019; Solanki 2012).
  • 31 studies were in paediatric populations; 10 were in adult populations; 10 were in mixed populations.

Arguments for…

• Overall 32/51 studies favoured local anaesthetic techniques for a reduction in pain scores and/or opioid consumption compared with placebo or control (Arikan 2008; Bayram 2015; Ghanei 2016; Kasapoglu 2013; Olson 2018; Debasish 2019; Park 2007; Aysenur 2014; Cocelli 2012; El Daly 2019; Ergil 2012; Fikret 2011; Ozkiris 2012; Ozmen 2011a; Ozmen 2011b; Sun 2015; Tas 2010; Tolska 2017; Turhan 2015; Unal 2007; Zadeh 2016; Oghan 2008; Saki 2015; Yilmaz 2009; Haksever 2014; Ahmed 2019; Inanoglu 2009; Junaid 2020; Mozafarinia 2007; Rajput 2019; Stelter 2009; Jahromi 2012):
  • 7/10 (70%) adult studies reported a reduction in pain scores after local anaesthetic techniques, while 15/31 (48%) paediatric studies and 10/10 (100%) of the mixed population studies were supportive of it.

Arguments against…

• No studies of local anaesthetic techniques included a basic analgesic regimen.
• The analgesic benefit reported in some studies was minor and limited to the very early postoperative period (Fikret 2011; Kasapoglu 2013).
• No evidence favouring one local anaesthetic agent over another was found.
• The technique of local anaesthetic infiltration was not standardised in the literature.
• Systemic absorption of local anaesthetic was an associated risk. Tonsillar infiltration may not be as safe as infiltration in other areas because of the neurovascular bundle in the vicinity that could explain high potential for side-effects. Indeed, three studies have reported complications including arrhythmias; bleeding; intravascular injection; and sedation.
  • Unal 2007 reported greater sedation scores with bupivacaine and ropivacaine infiltration compared with saline infiltration.
  • Tolska 2017 found that bleeding requiring haemostasis under local anaesthesia was more common in the ropivacaine group (10/54 (18%)) than in the control group (4/47 (8%)). One patient out of the 54 patients included in the ropivacaine group sustained postoperative bilateral pneumonia requiring 5 days of hospitalisation.
  • Junaid 2020 reported six transient cardiac arrhythmias out of the 30 enrolled patients in the bupivacaine infiltration group and concluded that there was an increased risk of complications.
• Bean-Lijewski 1997 described injection of 3–10 ml of bupivacaine 0.25–0.5% into each lateral pharyngeal space; the study was terminated after eight children had been enrolled because two out of four children receiving bupivacaine developed severe upper airway obstruction after tracheal extubation. This study concluded that bilateral local anaesthetic injection into the lateral pharyngeal space may induce an increased risk of severe upper airway obstruction and loss of protective reflexes.
• Only one study (Jahromi 2012) and one meta-analysis (Fedorowicz 2013) have been published since 2007 on the efficacy of lidocaine spray on postoperative pain after tonsillectomy.
  • Jahromi 2012 reported that lidocaine spray reduced pain scores for only 20 min after surgery when compared with saline or ketamine spray.
  • The meta-analysis was inconclusive as the risk of bias was high in most of the included trials and poor reporting quality and inadequate data did not permit comprehensive and reliable conclusions to be made (Fedorowicz 2013).
• Glossopharyngeal nerve block demonstrated advantages over normal saline injection or no injection in four studies involving 315 patients (Ahmed 2019; Debasish 2019; Park 2007; Mohamed 2009).
  • However, two of the studies reported severe complications. Park 2007 described intravascular injection and tachycardia in 1 out of 25 patients while Debasish 2019 reported hypotension and bradycardia in 2 out of 32 patients.

PROSPECT Recommendations

• Peritonsillar infiltration or topical application of local anaesthetics is not recommended, despite evidence of a short-lasting effect, due to concerns of serious side-effects.

Tonsillectomy-specific evidence

Data table: Ketamine infiltration or topical administration for pain management after tonsillectomy

• 11 studies examined ketamine infiltration for tonsillectomy analgesia (El Bahnasawy 2014; Dal 2007; Sonbaty 2011; Erhan 2007; Farmawy 2014; Honarmand 2008; Khademi 2011; Pirzadeh 2012; Siddiqui 2013; Ayatollahi 2012; Zokaei 2016).
  • All but one (Zokaei 2016) were in paediatric populations.
  • Nine studies compared ketamine infiltration with placebo (Dal 2007; Khademi 2011; El Bahnasawy 2014; Erhan 2007; Farmawy 2014; Honarmand 2008; Pirzadeh 2012; Siddiqui 2013; Ayatollahi 2012).
• Two studies investigated topical administration of ketamine in children (Tekelioglu 2013; Canbay 2008).

Arguments for…

• Ketamine infiltration was consistently effective in reducing pain and analgesic requirements after tonsillectomy in children:
  • Of nine studies comparing ketamine infiltration with placebo, eight showed a significant benefit for reduction of pain scores with ketamine infiltration (Dal 2007; Khademi 2011; El Bahnasawy 2014; Erhan 2007; Farmawy 2014; Honarmand 2008; Pirzadeh 2012; Siddiqui 2013).
  • One study comparing peritonsillar ketamine infiltration with IV ketamine showed reduced pain scores with infiltration (Khademi 2011).
  • One study compared ketamine with bupivacaine infiltration, alone or in combination. The combination of both was associated with reduced pain scores when compared with each drug alone (Zokaei 2016).
• Another study compared peritonsillar infiltration of ketamine with or without bupivacaine and meperidine, without any difference between each group (Sonbaty 2011).
• One study evaluated the effects of peritonsillar, IV or rectal administration of ketamine in children undergoing tonsillectomy and found all were as effective as IV tramadol (Yenigun 2015).

Arguments against…

• One study showed benefit of tramadol infiltration compared with peritonsillar ketamine infiltration for reduction of pain scores and opioid consumption (Ayatollahi 2012).
• Topical administration of ketamine was investigated in two studies; one showed higher pain scores with ketamine when compared with tramadol (Tekelioglu 2013) and the other showed improved analgesia compared with placebo and similar analgesia compared with IV morphine (Canbay 2008).

PROSPECT Recommendations

• Ketamine infiltration is not recommended because of the risks of systemic side-effects (hallucinations, agitation and sedation) after absorption.
• Topical administration of ketamine is not recommended due to limited procedure-specific evidence.

Tonsillectomy-specific evidence

Data table: Acupuncture for pain management after tonsillectomy

• One meta-analysis (Cho 2016) and seven studies involving 522 patients were included (Dingemann 2017; Gilbey 2015; Kager 2009; Plunkett 2018; Pouy 2019; Shah 2020; Tsao 2015).
• Four studies compared acupuncture with sham (Kager 2009; Tsao 2015; Pouy 2019; Shah 2020) and two with usual analgesic treatment (Dingemann 2017; Gilbey 2015).
• Time points of acupuncture were pre, intra- and postoperatively.

Arguments for…

• The majority of studies comparing acupuncture with sham or usual analgesic treatment reported a reduction in pain scores if acupuncture was used (Dingemann 2017; Gilbey 2015; Kager 2009; Pouy 2019; Shah 2020; Tsao 2015).
• No complications of acupuncture were described.

PROSPECT Recommendations

• Intra-operative and postoperative acupuncture is recommended as an analgesic adjunct (Grade B).

Tonsillectomy-specific evidence

Data table: Surgical approach for pain management after tonsillectomy

Surgical techniques for tonsillectomy: Descriptions

• Numerous studies examined surgical techniques, but these usually focused on outcomes such as bleeding, infection recurrence, hospital stay and costs. For this reason and because recent systematic reviews cover publications until 2016, only studies published between 2017 and 2019 are included in this review.
• Five randomised studies (Arbin 2017; Cetiner 2017; Sanlı 2017; Wiltshire 2018; Yilmazer 2017) and four systematic reviews (Alexiou 2011; Pynnonen 2017; Francis 2017; Metcalfe 2017) assessing the impact of surgical techniques on postoperative pain were included.

Arguments for…

• Coblation techniques have slightly less postoperative pain during the first day compared with cold dissection and electrocautery dissection techniques (Wiltshire 2018; Pynnonen 2017; Francis 2017; Metcalfe 2017), which seem to be similar in this aspect (Sanlı 2017; Yilmazer 2017; Metcalfe 2017).

Arguments against…

• Vessel seal technology is new and promising, but remains understudied and results are inconclusive so far (Alexiou 2011).

PROSPECT Recommendations

• PROSPECT cannot recommend a specific surgical technique that would influence pain after tonsillectomy, because most studies have evaluated surgical technique with respect to issues of bleeding as well as cost efficacy rather than postoperative pain.