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Post-Tonsillectomy Pain and Bupivacaine, An Intra Individual

Design Study
Amer Sabih Hydri1 and Sher Muhammad Malik2

Objective: To compare whether an individual could appreciate the pain relief, if any, in either one of his/her tonsillar fossa
topically suffused with a local anaesthetic (bupivacaine).
Study Design: Randomized controlled trial.
Place and Duration of Study: Department of ENT/Head and Neck Surgery, Combined Military Hospital, Peshawar, from
January to June 2007.
Methodology: Forty-six patients of either gender, aged 10-42 years undergoing tonsillectomy for recurrent tonsillitis were
enrolled for this study. At the end of surgery, having secured haemostasis, one tonsillar fossa was randomly packed with
a gauze piece soaked in 3 ml of 0.5% bupivacaine for 5 minutes, while the other was not. Effects of postoperative analgesia
were assessed using visual analogue scale (VAS) up to 8 hours.
Results: Majority of the patients (85%, n=39) failed to experience an appreciable pain relief on the side of local anaesthetic
(bupivacaine) application (p=0.006).
Conclusion: Topical application of local anaesthetic (bupivacaine) confers no appreciable pain control in post-tonsillectomy

Key words: Tonsillectomy. Pain. Bupivacaine. Local anaesthetic. Pain assessment.

INTRODUCTION study was designed to assess whether an individual

Managing pain following tonsillectomy remains a could appreciate the pain relief, if any, in either one of
confounding challenge for the anaesthetist and the his/her tonsillar fossa topically suffused with local
treating surgeon as it impairs swallowing, which subse- anaesthetic (bupivacaine).
quently leads to infection, dehydration and secondary
haemorrhage. The pain which peaks around the fourth
or fifth postoperative day1 translates into delayed Forty-six patients (92 tosillar fossae) of either gender,
recovery following surgery, prolonged hospital stay and American Society of Anaesthesiologists [ASA] physical
increased cost. Although adequate pain relief is status I, aged 10-42 years, undergoing tonsillectomy for
achieved with the use of narcotic analgesics yet their recurrent tonsillitis were enrolled for this double blind
use is fraught with adverse side effects. The patients randomized controlled trial. Written informed consent
often have to strike a balance between optimal pain was taken from the parents/ patients and approval of a
control and the side effects of the analgesics used.2 This protocol for this study was obtained from the local ethical
obviates the need to achieve adequate pain control committee. The minimum cut off age was 10 years so
using a local anaesthetic agent in conjunction with a that the patient was sensible and articulate enough to
general anaesthetic. interpret the visual analogue scale (VAS). Exclusion
criteria included known allergy to bupivacaine, painful
Bupivacaine, a long-acting local anaesthetic,3 is the conditions of the oropharynx like peritonsillitis and
most commonly reported local anaesthetic for paediatric peritonsillar abscess and conditions requiring surgery in
regional anaesthesia by virtue of its lower toxic threshold addition to tonsillectomy e.g. adenotonsillitis. Pre-
compared with other local anaesthetics.4 Various studies operatively, the patients/parents were instructed how to
have argued the effectiveness of topical application of express pain on a 100-mm scale (VAS). None of the
0.5% bupivacaine in reducing postoperative pain with patient was pre-medicated on the night prior to surgery.
conflicting results.5,6 Pain is a subjective feeling and the
All the tonsillectomies were performed using a standar-
thresholds vary from person to person, therefore, this
dized anaesthetic technique. Surgery was performed by
one of two senior otolaryngologists, using the same
1 Department of ENT, Combined Military Hospital, Pano Aqil. dissection and snare technique. The bleeding was
2 Department of ENT, Combined Military Hospital, Rawalpindi. controlled by bipolar diathermy.
Correspondence: Dr. Amer Sabih Hydri, Department of ENT, At the end of surgery, having secured haemostasis, one
Combined Military Hospital, Pano Aqil. tonsillar fossa was randomly packed with a cotton swab
E-mail: soaked in 3 ml of 0.5% bupivacaine for 5 minutes, while
Received July 28, 2009; accepted June 01, 2010. the other was not.

538 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 538-541
Post-tonsillectomy pain and bupivacaine, an intra individual design study

Following surgery, and after recovery from the general The cumulative mean VAS scores over the first 8 post-
anaesthetic, pain intensity in the throat, difficulty while operative hours for odynophagia revealed greater
talking and odynophagia, were assessed by asking discomfort than the scores for pain at rest and pain while
patients to express their pain, on a VAS 100 mm scale speaking (p=0.095, Table IV).
(0 mm: no pain; 100 mm: maximum imaginable pain) and Table IV: Mean pain scores ± (SD) for first 8 hours postoperatively
recorded at 1, 2, 4 and 8 hours after surgery. Separate (n=46).
recordings for each tonsillar fossa in the same patient Pain at rest Odynophagia Pain while speaking
were made by the recovery room/ward nursing staff and Bupivacaine 6.85 ± 1.04 7.18 ± 1.55 6.85 ± 1.04
treated fossae (4-9) (4-9) (4-9)
an intern, blinded to the side treated. Ibuprofen orally
Untreated fossae 6.49 ± 0.74 7.09 ± 1.16 6.49 ± 0.74
was given as a routine analgesic 6 hours following
(5-8) (5-9) (5-8)
surgery. No additional analgesic supplement was given
till the next 6 hours. VAS scores for pain at rest, odynophagia and pain while
The statistical analysis was performed using “software speaking, increased gradually, albeit asymmetrically in
package for statistical analysis” (SPSS-10). Pain scores both tonsillar fossae over the first 6 postoperative hours
using VAS were documented as mean ± standard and receded after oral analgesia was routinely given 6
deviation (SD). Student’s paired t-test was used for hours postoperatively. Thus the 8 hourly score was lower
than the one hour score in all cases (p=0.132, Figure 1).
calculating p-values. A p-value of < 0.005 was considered
significant. Only few patients [15%, n=7] experienced an appreci-
able pain relief on the side of topical bupivacaine
RESULTS application (p=0.006). An interesting observation was
that majority of patients [85%, n=39] had significantly
The mean age was 18.2 years. Most of the patients more pain on the side where bupivacaine packing of the
(61% n= 28) in this study were in or around their teen tonsil fossa was done, compared to the side where no
ages, followed by those in their third decade (26% intervention took place (Figure 2). Age and gender had
n=12). Male: female ratio was 1:1 (Table I). no bearing on this observation.
At the first VAS pain recording, one hour post-
operatively; all patients were too distraught to discrimi-
nate any pain difference between their respective
tonsillar fossae or any change during swallowing.
The VAS scores of pain intensity at rest and during
speech were identical, however, VAS scores on the
untreated side were lower than the fossae treated locally
with bupivacaine (p=0.156, Table II).
The overall pain intensity increased on swallowing. The
increase in VAS scores compared to pain at rest was
statistically insignificant, (p=0.134) in the untreated
fossae and (p=0.106) in the treated fossae. The treated
side was more painful than the untreated side (Table III).
Table I: Age and gender distribution (n=46). Figure 1: The mean VAS scores showing a gradual rise in the first three
1-10 years 11-20 years 21-30 years 31-40 years 41-50 years readings and a sudden fall after oral analgesia at the 6th postoperative hour.
Male 1 15 6 1 1
Female 2 13 6 1 0

Table II: Mean scores ± (SD) for pain at rest and during speech
1 hour 2 hours 4 hours 8 hours
Bupivacaine 6.46 ± 0.50 7.17 ± 1.04 8.13 ± 1.02 5.67 ± 1.17
treated fossae (6-7) (5-8) (6-9) (4-7)
Untreated fossae 6.46 ± 0.50 6.48 ± 0.50 7.43 ± 0.50 5.61 ± 0.49
(6-7) (6-7) (7-8) (5-6)

Table III: Mean scores ± (SD) for odynophagia (n=46).

1 hour 2 hours 4 hours 8 hours
Bupivacaine 6.46 ± 0.50 7.86 ± 1.08 8.43 ± 0.74 5.97 ± 1.14
treated fossae (6-7) (6-9) (7-9) (4-7)
Untreated 6.46 ± 0.50 7.71 ± 0.54 8.39 ± 0.49 5.82 ± 0.64
Figure 2: Effect of local application of bupivacaine on the tonsillar fossae.
fossae (6-7) (7-9) (8-9) (5-7) Only 15% patients (n=7) experienced pain relief (p=0.006).

Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 538-541 539
Amer Sabih Hydri and Sher Muhammad Malik

DISCUSSION to pain intensity and variation between the two tonsillar

In a bid to reduce post-tonsillectomy pain, variations in fossae. Since the readings were objective, the result
surgical procedures, antibiotic injections and intra ope- would surely be unreliable at best. Secondly bupi-
rative injection of corticosteroid have been attempted.7-9 vacaine is only effective locally up to 6-8 hours and
Perioperative local anaesthetics are often used to surely the concept of prolonged pain relief due to the
reduce the postoperative pain in tonsillectomy.10 There synergistic effect of a general/local anaesthetic is still
are different ways of applying local anaesthetics, include: hypothetical.
pre-incisional peritonsillar infiltration, post-tonsillectomy An interesting finding of this study that bupivacaine
wound infiltration and post-tonsillectomy packing with treated fossae were generally more painful is corro-
soaked gauze. borated by a study by Warnock19 who also observed that
There is a multitude of studies both supporting and children who had a bupivacaine infiltration of the tonsil
refuting the effectiveness of bupivacaine. Ginstrom fossa during surgery had significantly more pain in the
claimed that intraoperative infiltration of bupivacaine/ evening of surgery than children who did not.
epinephrine resulted in only a marginal effect on pain Another study by Nordahl concludes that bupivacaine is
and that too in the immediate postoperative period.11 ineffective in relieving post-tonsillectomy pain in females
Studies on bupivacaine infiltration in and around the and older patients who reported more pain and used
tonsillar fossae have yielded conflicting results varying more analgesics than males and younger patients.20
from no relief to appreciable pain control.12,13 Ventricular This corroborates the present findings, although in this
tachycardia has been documented as an isolated compli- study the discomfort on the treated side was not
cation of bupivacaine injection into the tonsillar bed.14 influenced by age or gender.
Wong concluded that postoperative bupivacaine injection A review of Cochrane database encompassing thirty
provides better pain relief than topical application.15 To trials till September 1998 reveals that since the trials
the contrary, Hung claimed that topical packing of identified were of small size and several involved the
bupivacaine-suffused packs confers pain relief.16 perioperative co-administration of intravenous opiates
Since the sides of intervention were pre-determined and which may have masked any beneficial effect of the local
not randomly selected, an element of bias cannot be anaesthetic, there is no evidence that the use of
ruled out in these studies. perioperative local anaesthetic in patients undergoing
tonsillectomy improves postoperative pain control.21
The pain threshold varies from person to person, yet
This commensurate with the findings of this study.
almost all the published studies have compared the pain
perception among different groups of individuals and not
between the tonsillar fossae of an individual. CONCLUSION
An exhaustive review of the Internet revealed only two Most of the patients i.e. 85% (n=39), failed to experience
studies that have an intra-individual design similar to an appreciable pain relief on the side of local anaes-
ours. This is the only way to correctly document the thetic (bupivacaine) application (p=0.006).
difference in pain perception after intervention in the Large scale randomised controlled trials with an intra-
same individual. individual design are needed to resolve the enigmatic
The first study by Somdas found that 0.5 % bupivacaine role of topical bupivacaine in tonsillectomy.
effectively relieves pain in children (patients aged 5-15), Acknowledgement: The authors would like to thank Dr.
which is in contrast to the findings of this study.17 The Jehangir Ahmed Afridi, Senior Intern, ENT Department,
two logical arguments are that considering the age Combined Military Hospital, Peshawar for his help in
group, most of the patients are too young to localize the collecting and compiling the VAS score data.
side of maximum pain and appreciate its severity on a
VAS scale. Secondly the side of intervention was not REFERENCES
randomly selected and 0.5% bupivacaine solution was 1. Farooq U, Sheikh SM, Hafeez A, Rafi T. Post tonsillectomy pain:
infiltrated on the right tonsillar bed in all cases. This can dissection ligation vs. bipolar electrodissection. Pak J Otolaryngol
generate a biased result. 2006; 22:37-8.
The only other intra-individual design study by Stelter 2. Gann TJ, Lubarsky DA, Flood EM, Thanh T, Manskopf J, Mayne
also claimed that post-tonsillectomy infiltration of the T, et al. Patients preferences for acute pain treatment. Br J Anaesth
2004; 92:681-8. Epub 2004 Mar 5.
wounds with bupivacaine is superior to pre-incisional
infiltration technique as well as post-tonsillectomy 3. Catterall W, Mackie K. Local anaesthetics. In: Hardman JG,
Limbird LE, Gilman AG, editors. Goodman and Gilman's the
packing of the wounds with a gauze swab.18 Pain
pharmacological basis of therapeutics. 9th ed. New York:
recordings were continued for 6 postoperative days. McGraw Hill; 1996.p. 331-47.
The arguments against this study are that the younger 4. Stelter K, Hempel JM, Berghaus A, Andratschke M, Luebbers
patients (age 3-45 years) are unable to respond accurately CW, Hagedorn H. Application methods of local anaesthetic

540 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 538-541
Post-tonsillectomy pain and bupivacaine, an intra individual design study

infiltrations for postoperative pain relief in tonsillectomy: a of post-tonsillectomy pain. A randomized, placebo controlled,double-
prospective, randomised, double-blind, clinical trial. Eur Arch blind study of 26 patients. Ear Nose Throat J 2009; 88:1121-7.
Otorhinolaryngol 2009; 266:1615-20. Epub 2009 Jan 22. 13. Akoglu E, Akkurt BC, Inanoglu K, Okuyucu S, Dagli S.
5. Naja MZ, El-Rajab M, Kabalan W, Ziade MF, Al-Tannir MA. Pre- Ropivacaine compared to bupivacaine for post-tonsillectomy
incisional infiltration for pediatric tonsillectomy: a randomized pain relief in children: a randomized controlled study. Int J Pediatr
double-blind clinical trial. Int J Pediatr Otorhinolaryngol 2005; Otolaryngol 2006; 70:1169-73. Epub 2006 Jan 18.
69:1333-41. Epub 2005 Apr 22. 14. Brown RE, Wilhoit RD, Samuel MP. Excessively high plasma
6. Unal Y, Pampal K, Korkmaz S, Arslan M, Zengin A, Kurtipek O. bupivacaine concentrations after tonsillar bed and adenoidal
Comparison of bupivacaine and ropivacaine on postoperative injection of 0.25% bupivacaine. Paediatr Anaesth 2007; 3:287-90.
pain after tonsillectomy in paediatric patients. Int J Otorhinolaryngol 15. Wong AK, Bissonnette B, Braude BM, Macdonald RM, St-Louis
2007; 71:83-7. Epub 2006 Nov 7. PJ, Fear DW. Post-tonsillectomy infiltration with bupivacaine
7. Sharif M, Zaman J, Yousaf N, Iqbal K. Diathermy tonsillectomy reduces immediate postoperative pain in children. Can J Anaesth
vs. conventional dissection tonsillectomy. J Postgrad Med Inst 2004; 1995; 42:770-4.
18:636-43. 16. Hung T, Moore-Gillon V, Hern J, Hinton A, Patel N. Topical
8. Burkart CM, Steward DL. Antibiotics for reduction of post- bupivacaine in paediatric day-case tonsillectomy: a prospective
tonsillectomy morbidity: a meta-analysis. Laryngoscope 2005; randomized controlled trial. J Laryngol Otol 2002; 116:33-6.
115:997-1002. 17. Somdas MA, Senturk M, Ketenci I, Erkorkmaz U, Unlu Y.
9. Afman CE, Welge JA, Steward DL. Steroids for post- Efficacy of bupivacaine for post-tonsillectomy pain: a study with the
tonsillectomy pain reduction: meta-analysis of randomized intra-individual design. Int J Pediatr Otolaryngol 2004; 68:1391-5.
controlled trials. Otolaryngol Head Neck Surg 2006; 134:181-6. 18. Warnock FF, Lander J. Pain progression, intensity and outcomes
10. Grainger J, Saravanappa N. Local anaesthetic for post- following tonsillectomy. Pain 1998; 75:37-45.
tonsillectomy pain: a systematic review and meta-analysis.
Clin Otolaryngol 2008; 33:411-9.
19. Nordahl SH, Albrektsen G, Guttormsen AB, Pedersen IL,
Breidablikk HJ. Effect of bupivacaine on pain after tonsillectomy:
11. Ginstrom R, Silvola R, Saarnivaara L. Local bupivacaine- a randomized clinical trial. Acta Otolaryngol 1999; 119:369-76.
epinephrine infiltration combined with general anesthesia for
adult tonsillectomy. Acta Otolaryngol 2005; 125:972-5.
20. Hollis L, Burton MJ, Millar M. Perioperative local anaesthesia for
reducing pain following tonsillectomy. Cochrane Database Syst Rev
12. Watts TL, Kountakis SE. Intraoperative bupivacaine for reduction 2000; (2):CD001874.

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