Abstract
Purpose
Post-tonsillectomy pain is a notable concern and thermal injury produced by electric surgical devices is considered a main cause. Intraoperative cooling of the tonsillar fossa and pharyngeal mucosa with cold water has effectively reduced postoperative pain, but no studies have fully evaluated the effects of this technique with a proper study design. We assessed mucosal cooling in two groups of patients undergoing the same surgical technique by a single surgeon, with one group receiving cold-water cooling and the other group as a control.
Methods
Forty patients who underwent monopolar electrocautery tonsillectomy were randomly assigned to two groups (n = 20 for each group). Group 1 received cooling of the tonsillar fossa and pharyngeal mucosa with 4 °C saline just after removal of each tonsil whereas Group 2 did not receive cooling. Postoperative pain was recorded on operation day and 1, 2, 4, 7, and 10 days postoperatively. Post-tonsillectomy pain, return to normal diet, and incidence of postoperative bleeding were compared between the groups.
Results
Post-tonsillectomy pain on 6 selected days and overall pain during the 10-day follow-up period were significantly lower in Group 1. However, return to normal diet and incidence of postoperative bleeding did not differ significantly between the groups.
Conclusions
Intraoperative application of cold water after tonsillectomy significantly reduced postoperative pain. We recommend cooling the tonsillar fossa and pharyngeal mucosa with cold water during tonsillectomy to easily and effectively reduce post-tonsillectomy pain.
1
Introduction
Tonsillectomy is one of the most common surgical procedures in otolaryngology. Postoperative pain is a notable drawback that can affect the duration of stay at a hospital, the returning period to work and social activities, and the patient’s diet . Thermal injury produced by electric surgical devices is the main cause of post-tonsillectomy pain and inflammatory mediators also induce pain by stimulating pharyngeal nociceptors . Therefore, a lower level of tissue damage and faster healing may be achieved by cold dissection rather than using other electric instruments. However, cold dissection requires a relatively longer operation time and postoperative pain is unavoidable even with this conservative and traditional technique. Recently, new surgical devices such as the Harmonic Scalpel, Coblator and bipolar scissors have been introduced . These instruments enable surgery to be performed at a significantly lower temperature (60–100 °C), minimizing thermal damage to the surrounding tissue and reducing postoperative pain. However, the effects on post-tonsillectomy pain between the various methods are still debatable and additional costs for the new devices should also be considered.
Cooling the pharyngeal mucosa using cold water (4 °C) has been reported to effectively reduce post-tonsillectomy pain . However, each report has had flaws in the study design or method, such as comparing two different surgical techniques, including patients who had uvulopalatoplasty, or using room-temperature water. Such conditions may have introduced bias into the results. Therefore, to accurately evaluate the benefit of cold-water cooling on post-tonsillectomy pain, procedures by a single surgeon using the same surgical technique and device are mandatory and cold-water cooling should be the only difference between the study and control groups. In this study, tonsillectomy was performed using monopolar electrocautery, which is the most widely used surgical device. We evaluated whether cooling the tonsillar fossa and pharyngeal mucosa with cold water immediately after tonsillectomy effectively reduces post-tonsillectomy pain. We also investigated overall pain, time to resuming the normal diet, incidence of postoperative bleeding, and number of patients who need additional medication, office or emergency room visit, or readmission for pain control.
2
Patients and methods
2.1
Patients
This prospective randomized clinical study examined 40 patients who underwent tonsillectomy using monopolar electrocautery from March to October 2013. The indication for surgery was recurrent or chronic tonsillitis. Patients were randomly allocated into two groups: Group 1 received cold-water cooling of the tonsillar fossa and pharyngeal wall immediately after tonsillectomy; Group 2 had no additional procedure after tonsillectomy. Patients were blinded whether they received cold-water cooling or not. The demographics of the patients in both groups are summarized in Table 1 . Randomization was performed using a statistical random number table.
| Group 1 | Group 2 | Total | |
|---|---|---|---|
| Number of patients | 20 | 20 | 40 |
| Male: Female | 10: 10 | 12: 8 | 22: 18 |
| Mean age (years) | 35.2 (13–54) | 36.7 (14–60) | 35.9 |
Exclusion criteria were as follows: 1) patients 10 years old or younger; 2) patients with significant medical morbidities; 3) active tonsillar infection; 4) patients who declined to participate or who did not complete the questionnaire. Informed consent was obtained from all patients, and the study was approved by the Institutional Review Board of the Soonchunhyang University.
2.2
Surgical procedures and outcome measures
The same surgeon (J.Y.L.) performed all surgical procedures under general anesthesia. After adequate exposure of the oral cavity with a McIvor tongue retractor, each tonsil was dissected in the extracapsular plane using monopolar electrocautery with a coagulation mode of 20 W. Hemostasis was achieved by minimal spot electrocautery using bipolar forceps. For Group 1 patients, immediately following removal of each tonsil, each tonsillar fossa was irrigated with 4 °C normal saline. Using a 50 mL syringe, a total of 300 mL cooled saline was used to irrigate each side. At the end of the surgery, 4 °C saline was poured into the oral cavity and oropharynx to the level of the uvula base for additional cooling of the tonsillar fossae and pharyngeal wall, and then aspirated out after 5 min. In Group 2, the oral cavity, including the tonsillar fossae and pharyngeal wall, was cleaned with a saline-soaked cotton pledget at room temperature to moisten the dried mucosa after removal of both tonsils. All patients in both groups were prescribed pain medication (acetaminophen) three times per day for 1 week.
The primary outcome measure was postoperative pain, and subjective pain was evaluated using a visual analogue scale (VAS) from 0 to 10. A score of 0 indicated no pain or disturbances, and a score of 10 indicated the most painful state imaginable. A questionnaire was administered to the patients and they were asked to record their pain level on operation day and 1, 2, 4, 7, and 10 days postoperatively. To avoid possible effects of the medication, we asked patients to record the degree of postoperative pain in the morning before any pain medicine was administered. Patients were also asked to estimate their overall pain during the 10-day period using the same VAS. Secondary outcome measures were period to return to normal diet and incidence of postoperative bleeding. When a patient can take usual meals without pain or discomfort after 7-day soft diet, the total period from the operation was defined as a returning period to normal diet. Number of patients who need additional medication, office or emergency room visit, or readmission for pain control was also investigated. We collected the completed questionnaires on postoperative day 15 for review and analysis.
2.3
Statistical analysis
We analyzed the results of the study using the Mann–Whitney test. Statistical analyses were carried out using SPSS Software version 16.0 (Chicago, IL), and statistical significance was defined as p < 0.05.
2
Patients and methods
2.1
Patients
This prospective randomized clinical study examined 40 patients who underwent tonsillectomy using monopolar electrocautery from March to October 2013. The indication for surgery was recurrent or chronic tonsillitis. Patients were randomly allocated into two groups: Group 1 received cold-water cooling of the tonsillar fossa and pharyngeal wall immediately after tonsillectomy; Group 2 had no additional procedure after tonsillectomy. Patients were blinded whether they received cold-water cooling or not. The demographics of the patients in both groups are summarized in Table 1 . Randomization was performed using a statistical random number table.
| Group 1 | Group 2 | Total | |
|---|---|---|---|
| Number of patients | 20 | 20 | 40 |
| Male: Female | 10: 10 | 12: 8 | 22: 18 |
| Mean age (years) | 35.2 (13–54) | 36.7 (14–60) | 35.9 |
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