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

Arguments against…

• Two studies investigated postoperative administration of dexamethasone (Lachance 2008; Vaiman 2011). Neither study showed a significant reduction of postoperative pain scores compared with placebo.

PROSPECT Recommendations

• Postoperative dexamethasone is not recommended due to lack of 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: Honey for pain management after tonsillectomy

• The efficacy of postoperative honey as an analgesic adjuvant was tested in seven studies including a total of 547 patients:
  • Only one study included adults exclusively (Hatami 2018)
  • Two studies included a mixed population (Letchumanan 2013; Prasad 2015)
  • The four other studies were performed in children (Abdullah 2015; Amani 2015; Boroumand 2013; Mohebbi 2014).

Arguments for…

• Three studies reported a reduction in pain scores and postoperative analgesic consumption when honey was administered on top of a basic analgesic regimen containing either paracetamol or NSAIDs (Boroumand 2013; Mohebbi 2014; Prasad 2015) with no significant side-effects.
• Two meta-analyses (Lal 2017; Hwang 2016) reported a benefit in terms of pain and a reduction in analgesic requirements, issuing low or very low-grade recommendations.
• An additional positive outcome in these meta-analyses was improved wound healing associated with the use of honey (Lal 2017; Hwang 2016).

Arguments against…

• The analgesic effect of honey was minor and the sample size was small in most studies, varying from 42 to 111 patients per study, suggesting further research in the majority of reports.

PROSPECT Recommendations

• Postoperative honey is recommended as an analgesic adjunct (Grade B).

Tonsillectomy-specific evidence

Data table: Communication for pain management after tonsillectomy

• Six studies in children (Almasi 2016; Bailey 2015; Helgadottir 2014; Martin 2014; Paquette 2013; Vallee 2008) and one in adults (Van Vliet 2020) examined different methods to improve communication with patients or parents for better compliance with analgesics.

Arguments for…

• The majority of studies recommend enhanced parental education and/or telephone follow-up to observe the need for analgesics at home and their side-effects.

Arguments against…

• Most studies on communication about postoperative pain management were small and of poor quality.

PROSPECT Recommendations

• PROSPECT cannot make recommendations regarding communication with patients or parents about postoperative pain management, as there is limited and inconsistent procedure-specific evidence regarding the impact on pain scores and analgesic consumption.

Tonsillectomy-specific evidence

Data table: Dietary protocols for pain management after tonsillectomy

• Eight studies assessed the effects of different dietary protocols on post-tonsillectomy pain and complications:
  • Six studies in children (Faramarzi 2018; Moghaddam 2014; Klemetti 2009; Manica 2018; Meybodian 2019; Sylvester 2011), one in adults (Koçak 2018) and one with mixed age population (Wijakkanalan 2015) were included.

Arguments for…

• Ice lolly use was effective in reducing pain scores for 1 hour postoperatively (Sylvester 2011).
• Minimising fasting time to 4 hours for solids and 2 hours for liquids improved postoperative outcomes in terms of analgesic requirements and postoperative nausea and vomiting in two studies (Moghaddam 2014; Klemetti 2009).
• Only one study (Koçak 2018), which was of poor quality and included 49 participants, suggested effective analgesia and improved wound healing with the administration of ginger capsules postoperatively.

Arguments against…

• Four studies (Faramarzi 2018; Manica 2018; Meybodian 2019; Wijakkanalan 2015) with 204 participants did not demonstrate any benefit of restricting postoperative diet to liquids or to cold diet when pain scores, nausea or vomiting or bleeding were compared.

PROSPECT Recommendations

• PROSPECT cannot make recommendations about dietary protocols for postoperative pain management, as there is limited procedure-specific evidence from heterogeneous studies.