Tonsillectomy can cause moderate to severe postoperative pain for several days after surgery. German 4.1.1, p 8, German 4.1.1.2.1, p 10. Tonsillectomy is most commonly carried out in children but also in adults.

Evidence-based treatment recommendations specific to the condition

Intraoperative

Systemic analgesia

• Intra-operative dexamethasone reduces acute pain, nausea and vomiting, and ibuprofen requirements following tonsillectomy, but may lead to increased postoperative risk of bleeding ANZCA chapter 9 p 276.
• Antibiotics do not decrease postoperative pain but facilitate early rehabilitation German section 4.1.1.2.4. p15.

Local analgesia

• Peritonsillar infiltration with a long acting local anesthetic produces a modest reduction in acute post-tonsillectomy pain ANZCA chapter 9 p 275; German section 4.1.1.2.3, p 10.
• Peritonsillar infiltration with tramadol or ketamine may reduce post-tonsillectomy pain and analgesia requirements but was no more effective than equivalent doses administered parenterally. ANZCA chapter 9 p 275-276.
• Topical local anesthetic on swabs may be as effective as infiltration, with a lower incidence of adverse effects ANZCA chapter 7.5.4. p 200-201.

Postoperative

• Combining NSAIDs and paracetamol provided effective analgesia and \ decreased the need for supplementary analgesics following tonsillectomy ANZAC chapter 10.5.2, p 348.
• As a single drug, paracetamol does not effectively reduce post-tonsillectomy pain but it can be combined with metamizol or cox-2 specific inhibitors. Due to their negligible effect on plasma coagulation and thrombocyte function, this combination is preferable compared to nsNSAIDs German 4.1.1.2.4, p11.
• Intravenous paracetamol given every 6 hours on the first postoperative day reduces pain and requirements for rescue analgesia in adults ANZCA chapter 9, ‘acute post-tonsillectomy pain’, p 276.
• Cox-2 specific inhibitors may provide analgesia for 24 hours after tonsillectomy, with decreased nausea and no increased blood loss ANZCA chapter 9 p 280.
• Gabapentin may reduce analgesic requirements for up to 48 hours, and pain on swallowing for up to 4 hours, in adults ANZCA chapter 9, ‘acute post-tonsillectomy pain’, p 276.
• Some non-selective NSAIDs and aspirin, increase the need for reoperation due to bleeding (NNH 29 to 60) but were not associated with significantly increased blood loss. ANZCA chapter 9, ‘acute post-tonsillectomy pain’, p 276.
• For every 100 patients undergoing tonsillectomy and treated with NSAID, 2 more will need a reoperation because of bleeding but 9 fewer will have PONV, compared with those treated with other analgesics, or opioids. Bandolier

Non-pharmacological interventions

• Homeopathic arnica has been shown to significantly reduce acute pain after tonsillectomy ANZCA chapter 4.3.10 page 96.

Advice/guidance to patients

If surgery is carried out as an ambulatory procedure, patients (parents, in case of children) should be made aware of the risk of bleeding.

Issues related to nursing/monitoring of patients

Tonsillectomy may be performed as an ambulatory procedure, requiring adequate postoperative pain management. Inadequate analgesia may delay patient discharge and cause nausea and vomiting. ANZCA chapter 9.1.4 p 238.

The severity of pain during swallowing and difficulty in eating may require that analgesics are administered intravenously in the early postoperative period. German 4.1.1 ,p 9.

Summary

Tonsillectomy may cause severe postoperative pain, which needs to be managed with a multimodal approach incorporating regular intravenous and oral analgesics, anti-emetics and opioids as required.

Supplementary reading

1. Baugh RF, Archer SM, Mitchell RB,et al American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011 Jan;144(1 Suppl):S1-30. http://oto.sagepub.com/content/144/1_suppl/S1