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Tonsillectomy by guillotine is less painful than by dissection
International Journal of Pediatric Otorhinolaryngology 52 (2000) 25 – 29 www.elsevier.com/locate/ijporl
Tonsillectomy by guillotine is less painful than by dissection J.J. Homer a,*, B.T. Williams b, P. Semple b, A. Swanepoel b, L.C. Knight a a
Department of Otolaryngology-Head and Neck Surgery, St James’s Uni6ersity Hospital, Leeds, UK b Department of Anaesthesia, St James’s Uni6ersity Hospital, Leeds, UK Received 21 May 1999; received in revised form 11 September 1999; accepted 11 October 1999
Abstract Most tonsillectomies are carried out by dissection. Only a small minority of otolaryngologists still routinely perform guillotine tonsillectomy. We carried out a prospective study on 86 children undergoing tonsillectomy utilising a standard anaesthetic and analgesic regimen to compare post-operative pain after dissection tonsillectomy and guillotine tonsillectomy using a Popper’s hemostatic guillotine. Guillotine tonsillectomy was significantly less painful (PB 0.001) than dissection tonsillectomy. The relative risk of experiencing moderately severe to severe pain was 0.36 (95% CI, 0.18–0.72) in the guillotine group. A significant proportion of children experience moderately severe to severe pain despite a comprehensive analgesic regimen confirming that post operative pain remains an important issue after this operation. On the basis of our findings we advocate tonsillectomy by guillotine in children. The less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tonsillectomy; Day-case; Pain
1. Introduction Tonsillectomy is one of the most frequent operations carried out in childhood, with 2.3:1000 children under 12 years having the operation in the UK [1]. Pain following tonsillectomy attracts a great deal of interest and research because of this and because post-tonsillectomy pain is difficult to manage and tends to be underestimated [2]. It has been shown that it is safe with regard to reactionary hemorrhage to discharge patients 6 – 8 * Corresponding author. Present address: 7 Oakwood Drive, Leeds LS8 2JB, UK.
h post-operatively [3,4]. As a result of this, there is an increasing trend to perform tonsillectomy as a day case procedure in the UK [5], which is the norm in North America. Pain in the first 24 h post-operatively is therefore a particularly important issue. Guillotine tonsillectomy used to be the method of choice for many generations of otolaryngologists in the UK but is only now carried out by a small minority of surgeons [6]. Concerns arose primarily because of the high primary and reactive hemorrhage rate in association with an unprotected airway. However, in contrast to three to four decades ago, patients are fully anaesthetised and intubated providing airway protection and
0165-5876/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 9 6 - 7
26
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29
time for additional hemostasis after the guillotining if necessary. As a result, tonsillectomy by guillotine can be used in today’s improved anaesthetic environment with safety and no higher hemorrhage rate [7]. Wake and Glossop in a randomised double blind prospective trial showed that guillotine tonsillectomy resulted in less operative blood loss and less post-operative pain of shorter duration than after dissection tonsillectomy in children. Pain severity was assessed by the amount of paracetamol given by nursing staff ‘on request’ [8]. A study by Weligodapola also showed less post-operative pain with dissection but this study compared one tonsil with another in the same patient (i.e. left vs. right) and the children were simply asked to indicate which side was most painful [9]. In this study, we wished to assess pain that occurs in the first 24-h post-operative period despite the use of a comprehensive analgesic regimen. By using a structured pain assessment tool for children [10], we hoped to minimise subjectivity and gain a meaningful measurement of the severity of pain. We performed a prospective study comparing pain in the first 24 h post-operatively after guillotine and dissection tonsillectomy.
to which list the patients were on. All patients were operated on a morning list and were looked after by the same ward and operating theatre staff. Patients with contraindications to nonsteroidal anti-inflammatory drugs (NSAIDS) were excluded. A total of 86 children were recruited, 43 children on each list consecutively. The surgery was carried out by one of two surgeons. All patients were discharged from hospital the following morning.
2.1. Surgical method All patients were positioned supine with a shoulder bag placed under the shoulders. Patients undergoing dissection tonsillectomy had a Boyle– Davis gag inserted. There was no deviation from the standard dissection technique described elsewhere [11]. Hemostasis was achieved using bipolar diathermy. Patients undergoing guillotine tonsillectomy had a Doyen’s mouth gag inserted. The tonsils were then introduced into the Popper guillotine and guillotined after being crushed. A Boyle–Davis gag is then introduced and hemostasis if required achieved using bipolar diathermy.
2.2. Anaesthetic regimen 2. Methods The study was approved by the hospital ethical committee and informed parental/guardian consent was obtained on behalf of the children studied. Children between the ages of 3 – 15 years listed for tonsillectomy (only) were included. Half the patients were operated on using a Popper’s guillotine and in the other half a dissection technique was used. Allocation was made according Table 1 Patient characteristics
Number in group Mean age (years) Mean weight (kg) Weight standard deviation
All patients received the same anaesthetic regimen. EMLA cream was applied to both hands. Anaesthesia was induced using 3–4 mg/kg propofol via a 22-gauge cannula. Tracheal intubation was facilitated by suxamethonium 1 mg/kg. All patients received a prophylactic anti-emetic and fentanyl 1 mg/kg was used for opioid analgesia. After induction of anaesthesia all patients immediately received paracetamol and diclofenac suppositories. Anaesthesia was maintained with spontaneous respiration of nitrous oxide, oxygen and an inhalational anaesthetic agent. Anaesthesia was given by one of three anaesthetists.
Guillotine
Dissection
2.3. Post-operati6e analgesia and pain assessment
42 7.2 24.2 11.9
42 7.4 23.1 8.1
Post-operative analgesia was given according to a regimen such that each patient received regular paracetamol syrup 12.5 mg/kg 6 hourly and diclofenac 1 mg/kg orally 8 hourly (Table 1).
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29 Table 2 Total paracetamol and diclofenac doses
Total paracetamol (mg/kg) Total diclofenac (mg/kg)
Guillotine
Dissection
P-value (t-test)
74.1
75.8
0.64
3
2.9
0.57
27
Codeine 1 mg/kg orally was given if a child had a persistent pain score of 2 or more not relieved by regular analgesia. Post-operative pain scores were regularly performed by nursing staff at 2-h intervals. The pain assessment tool is a modification of the PATCH tool where pain is scored from 0 (no pain) to 4 (severe pain) using a structured combination of nurse observation and child assessment using faces, descriptive words, a numerical visual scale and child behaviour [10]. Pain scores for the two groups were compared at warding, 8 and 24 h and the maximum pain score during the 24-h period was also noted.
2.4. Statistical analysis The SPSS 8.0 computer software package was used for statistical analysis. Parametric data for the two groups was analysed using Levene’s test for equality of variances and t-tests for equality of means. The Mann–Whitney U-test was used to compare the pain scores for the groups. The x 2-test was used to compare proportions for rescue analgesia. Relative risk was calculated from two by two tables. Fig. 1. Bar chart of the sum of post-operative pain scores (0–4) for each group. *Significant difference between the groups, P B 0.05.
3. Results
Fig. 2. Bar chart showing the maximum post-operative pain scores of patients in the two groups.
There was one protocol violation from each group when post-operative diclofenac was not given as the patients were assumed to be asthmatic. These patients were excluded from the study. There were no post-operative complications in either group. Both groups of 42 children were similar with respect to age and weight (Table 1). There were no significant differences between the groups in the amount of per-operative or post-operative paracetamol or diclofenac (Table 2). At warding there was a trend towards higher pain scores in the dissection group but this was not significant (P=0.106). Pain scores were significantly higher at 8 h (P= 0.003) and 24 h (P= 0.037) post-operatively in the dissection group (Fig. 1). Maximum pain scores were significantly higher in the dissection group (P=0.001) (Figs. 1 and 2). The rela-
28
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29
tive risk of experiencing moderate to severe pain (pain score \ 2) in the guillotine group was 0.36 (95% confidence interval, 0.18 – 0.72). The dissection group required a significantly greater number of doses of codeine rescue analgesia (11/42 and 3/42, respectively, P =0.02).
4. Discussion We have shown that guillotine tonsillectomy is less painful than dissection tonsillectomy. The difference is most apparent when in the maximum recorded pain scores where 22/42 (52%) of the children in the dissection group had pain scores of 3 or 4 (moderately severe or severe pain) at some time during the first 24 h post-operatively. This compares with 8/42 (19%) in the guillotine group (i.e. a relative risk of approximately one-third). This difference is emphasised by a significantly greater requirement for ‘rescue’ analgesia in the dissection group. These results agree with Wake and Glossop’s in terms of reduced pain after guillotine tonsillectomy. Their conclusion regarding the duration of pain being less after guillotine agrees with our published audit figures. They found a mean duration of pain for 2.3 days after guillotine tonsillectomy and 5.7 days after dissection tonsillectomy. Our figures are 3.6 and 6.9, respectively [12]. Our study specifically measures pain as objectively as possible by a trained independent observer using a structured measuring tool. This also has the advantage in that we gained a meaningful measure of the severity of pain that arises despite the use of a comprehensive analgesic regimen. Post-tonsillectomy pain is notoriously difficult to manage and often underestimated [2]. Our results support that statement. In our study we used a comprehensive combination of analgesia through different routes. NSAIDS combined with paracetamol are thought to be effective for patients following tonsillectomy [13,14]. We also used per-operative fentanyl which has been shown to enhance the post-operative analgesia attained using NSAIDS [15]. Despite this, 52 and 19% in the two groups of children are in moderately severe or severe pain and require rescue analgesia
at some point during the first 24 post-operative hours. On the basis of our findings we advocate tonsillectomy by guillotine in children and the less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure. The guillotine method has fallen into disrepute because of an association with haemorrhage and incomplete tonsil excision, leaving remnants behind. However, with time for hemostasis at the end of the procedure, and with the design of the Popper’s guillotine (where the tonsil capsule is crushed before being guillotined), higher hemorrhage rates have not been observed [7]. There is also no higher rate of tonsil remnants [8]. We find occasionally in children that it is not possible to introduce the tonsil into the guillotine on account of excessive fibrosis around the tonsil. In these cases a dissection technique has to be followed. For this reason, we find the guillotine technique not suitable for adult tonsillectomies. However with most children there is no problem and complete excision takes place. Even when the tonsils appear to be buried, by pushing them through the guillotine via the anterior faucal pilla, the tonsil is, in effect, being dissected as it enters the guillotine in this way. Clearly there is a learning curve in using the guillotine. In addition to being less painful, the technique is quicker and with less per-operative blood loss than dissection [8]. A criticism of the study is the lack of allocation by randomisation between the two groups. Nevertheless the general population from which the patients were drawn, the anaesthetic protocol, operating theatre and ward staff and the post-operative nursing care were the same for both groups.
5. Conclusion Tonsillectomy by guillotine results in less pain in the first post-operative 24 h. Post-operative pain, despite a comprehensive analgesic regimen remains a significant problem following tonsillectomy.
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29
29
[8] M. Wake, P. Glossop, Guillotine and dissection tonsillectomy compared, J. Laryngol. Otol. 103 (1989) 588 – 591. [9] G.S. Weligodapola, Comparative study of tonsillectomy performed by guillotine and dissection methods, J. Laryngol. Otol. 97 (1983) 605 – 606. [10] R. Qureshi, O.R. Buckingham, A pain assessment tool for all children, Paediatr. Nursing 6 (1994) 11 – 13. [11] Cowan, D.L., Hibbert, J., 1997. Tonsils and adenoids. In: Kerr, A.G. (Ed.), Scott-Browns’s Otolaryngology. 6th edn. Butterworth-Heinemann, Oxford, 6/18/9 – 11. [12] P. Semple, J. Swallow, L. Knight, Post-tonsillectomy: ‘a pain at home’, Yorkshire Med. 10 (1997) 30 – 32. [13] M.E. Bone, D. Fell, A comparison of rectal diclofenac with intramuscular papaveretum or placebo for pain relief following tonsillectomy, Anaesthesia 43 (1988) 277 – 280. [14] C.H. Watters, C.C. Patterson, H.M.L. Matthews, W. Campbell, Diclofenac sodium for post-tonsillectomy pain in children, Anaesthesia 43 (1988) 641 – 643. [15] J.E. Mendham, S.J. Mather, Comparison of diclofenac and tenoxicam for post-operative analgesia with and without fentanyl in children undergoing adenotonsillectomy or tonsillectomy, Paediatr. Anaesth. 17 (1996) 517 – 519.
References [1] McKerrow, W.S., 1998. Tonsillectomy and adenoidectomy. In: Statements of Clinical Effectiveness. British Association of Otorhinolaryngologists Head and Neck Surgeons, pp. 49 – 61. [2] H.M. Myatt, R.A. Myatt, The development of pediatric quality of life questionnaire to measure post-operative pain following tonsillectomy, Int. J. Pediatr. Otolaryngol. 44 (1998) 115 – 123. [3] A.K. Tewary, Day-case tonsillectomy: a review of the literature, J. Laryngol. Otol. 107 (1993) 703–705. [4] M.P.J. Yardley, Tonsillectomy, adenoidectomy and adenotonsillectomy: are they safe day case procedures?, J. Laryngol. Otol. 106 (1992) 299–300. [5] M.B. Pringle, E. Cosford, P. Beasley, A.P. Brightwell, Day-case tonsillectomy — is it appropriate?, Clin. Otolaryngol. 21 (1996) 504–511. [6] Blair, R.L., McKerrow, W.S., Carter, N.W., Fenton, A., 1996. The Scottish tonsillectomy audit. J. Laryngol. Otol. 110(Suppl. 20). [7] C. Roberts, S. Jayaramachandran, C.H. Raine, A prospective study of factors which may predispose to post-operative tonsillar fossa haemorrhage, Clin. Otolaryngol. 17 (1992) 13 –17.
.
Tonsillectomy by guillotine is less painful than by dissection J.J. Homer a,*, B.T. Williams b, P. Semple b, A. Swanepoel b, L.C. Knight a a
Department of Otolaryngology-Head and Neck Surgery, St James’s Uni6ersity Hospital, Leeds, UK b Department of Anaesthesia, St James’s Uni6ersity Hospital, Leeds, UK Received 21 May 1999; received in revised form 11 September 1999; accepted 11 October 1999
Abstract Most tonsillectomies are carried out by dissection. Only a small minority of otolaryngologists still routinely perform guillotine tonsillectomy. We carried out a prospective study on 86 children undergoing tonsillectomy utilising a standard anaesthetic and analgesic regimen to compare post-operative pain after dissection tonsillectomy and guillotine tonsillectomy using a Popper’s hemostatic guillotine. Guillotine tonsillectomy was significantly less painful (PB 0.001) than dissection tonsillectomy. The relative risk of experiencing moderately severe to severe pain was 0.36 (95% CI, 0.18–0.72) in the guillotine group. A significant proportion of children experience moderately severe to severe pain despite a comprehensive analgesic regimen confirming that post operative pain remains an important issue after this operation. On the basis of our findings we advocate tonsillectomy by guillotine in children. The less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tonsillectomy; Day-case; Pain
1. Introduction Tonsillectomy is one of the most frequent operations carried out in childhood, with 2.3:1000 children under 12 years having the operation in the UK [1]. Pain following tonsillectomy attracts a great deal of interest and research because of this and because post-tonsillectomy pain is difficult to manage and tends to be underestimated [2]. It has been shown that it is safe with regard to reactionary hemorrhage to discharge patients 6 – 8 * Corresponding author. Present address: 7 Oakwood Drive, Leeds LS8 2JB, UK.
h post-operatively [3,4]. As a result of this, there is an increasing trend to perform tonsillectomy as a day case procedure in the UK [5], which is the norm in North America. Pain in the first 24 h post-operatively is therefore a particularly important issue. Guillotine tonsillectomy used to be the method of choice for many generations of otolaryngologists in the UK but is only now carried out by a small minority of surgeons [6]. Concerns arose primarily because of the high primary and reactive hemorrhage rate in association with an unprotected airway. However, in contrast to three to four decades ago, patients are fully anaesthetised and intubated providing airway protection and
0165-5876/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 2 9 6 - 7
26
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29
time for additional hemostasis after the guillotining if necessary. As a result, tonsillectomy by guillotine can be used in today’s improved anaesthetic environment with safety and no higher hemorrhage rate [7]. Wake and Glossop in a randomised double blind prospective trial showed that guillotine tonsillectomy resulted in less operative blood loss and less post-operative pain of shorter duration than after dissection tonsillectomy in children. Pain severity was assessed by the amount of paracetamol given by nursing staff ‘on request’ [8]. A study by Weligodapola also showed less post-operative pain with dissection but this study compared one tonsil with another in the same patient (i.e. left vs. right) and the children were simply asked to indicate which side was most painful [9]. In this study, we wished to assess pain that occurs in the first 24-h post-operative period despite the use of a comprehensive analgesic regimen. By using a structured pain assessment tool for children [10], we hoped to minimise subjectivity and gain a meaningful measurement of the severity of pain. We performed a prospective study comparing pain in the first 24 h post-operatively after guillotine and dissection tonsillectomy.
to which list the patients were on. All patients were operated on a morning list and were looked after by the same ward and operating theatre staff. Patients with contraindications to nonsteroidal anti-inflammatory drugs (NSAIDS) were excluded. A total of 86 children were recruited, 43 children on each list consecutively. The surgery was carried out by one of two surgeons. All patients were discharged from hospital the following morning.
2.1. Surgical method All patients were positioned supine with a shoulder bag placed under the shoulders. Patients undergoing dissection tonsillectomy had a Boyle– Davis gag inserted. There was no deviation from the standard dissection technique described elsewhere [11]. Hemostasis was achieved using bipolar diathermy. Patients undergoing guillotine tonsillectomy had a Doyen’s mouth gag inserted. The tonsils were then introduced into the Popper guillotine and guillotined after being crushed. A Boyle–Davis gag is then introduced and hemostasis if required achieved using bipolar diathermy.
2.2. Anaesthetic regimen 2. Methods The study was approved by the hospital ethical committee and informed parental/guardian consent was obtained on behalf of the children studied. Children between the ages of 3 – 15 years listed for tonsillectomy (only) were included. Half the patients were operated on using a Popper’s guillotine and in the other half a dissection technique was used. Allocation was made according Table 1 Patient characteristics
Number in group Mean age (years) Mean weight (kg) Weight standard deviation
All patients received the same anaesthetic regimen. EMLA cream was applied to both hands. Anaesthesia was induced using 3–4 mg/kg propofol via a 22-gauge cannula. Tracheal intubation was facilitated by suxamethonium 1 mg/kg. All patients received a prophylactic anti-emetic and fentanyl 1 mg/kg was used for opioid analgesia. After induction of anaesthesia all patients immediately received paracetamol and diclofenac suppositories. Anaesthesia was maintained with spontaneous respiration of nitrous oxide, oxygen and an inhalational anaesthetic agent. Anaesthesia was given by one of three anaesthetists.
Guillotine
Dissection
2.3. Post-operati6e analgesia and pain assessment
42 7.2 24.2 11.9
42 7.4 23.1 8.1
Post-operative analgesia was given according to a regimen such that each patient received regular paracetamol syrup 12.5 mg/kg 6 hourly and diclofenac 1 mg/kg orally 8 hourly (Table 1).
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29 Table 2 Total paracetamol and diclofenac doses
Total paracetamol (mg/kg) Total diclofenac (mg/kg)
Guillotine
Dissection
P-value (t-test)
74.1
75.8
0.64
3
2.9
0.57
27
Codeine 1 mg/kg orally was given if a child had a persistent pain score of 2 or more not relieved by regular analgesia. Post-operative pain scores were regularly performed by nursing staff at 2-h intervals. The pain assessment tool is a modification of the PATCH tool where pain is scored from 0 (no pain) to 4 (severe pain) using a structured combination of nurse observation and child assessment using faces, descriptive words, a numerical visual scale and child behaviour [10]. Pain scores for the two groups were compared at warding, 8 and 24 h and the maximum pain score during the 24-h period was also noted.
2.4. Statistical analysis The SPSS 8.0 computer software package was used for statistical analysis. Parametric data for the two groups was analysed using Levene’s test for equality of variances and t-tests for equality of means. The Mann–Whitney U-test was used to compare the pain scores for the groups. The x 2-test was used to compare proportions for rescue analgesia. Relative risk was calculated from two by two tables. Fig. 1. Bar chart of the sum of post-operative pain scores (0–4) for each group. *Significant difference between the groups, P B 0.05.
3. Results
Fig. 2. Bar chart showing the maximum post-operative pain scores of patients in the two groups.
There was one protocol violation from each group when post-operative diclofenac was not given as the patients were assumed to be asthmatic. These patients were excluded from the study. There were no post-operative complications in either group. Both groups of 42 children were similar with respect to age and weight (Table 1). There were no significant differences between the groups in the amount of per-operative or post-operative paracetamol or diclofenac (Table 2). At warding there was a trend towards higher pain scores in the dissection group but this was not significant (P=0.106). Pain scores were significantly higher at 8 h (P= 0.003) and 24 h (P= 0.037) post-operatively in the dissection group (Fig. 1). Maximum pain scores were significantly higher in the dissection group (P=0.001) (Figs. 1 and 2). The rela-
28
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29
tive risk of experiencing moderate to severe pain (pain score \ 2) in the guillotine group was 0.36 (95% confidence interval, 0.18 – 0.72). The dissection group required a significantly greater number of doses of codeine rescue analgesia (11/42 and 3/42, respectively, P =0.02).
4. Discussion We have shown that guillotine tonsillectomy is less painful than dissection tonsillectomy. The difference is most apparent when in the maximum recorded pain scores where 22/42 (52%) of the children in the dissection group had pain scores of 3 or 4 (moderately severe or severe pain) at some time during the first 24 h post-operatively. This compares with 8/42 (19%) in the guillotine group (i.e. a relative risk of approximately one-third). This difference is emphasised by a significantly greater requirement for ‘rescue’ analgesia in the dissection group. These results agree with Wake and Glossop’s in terms of reduced pain after guillotine tonsillectomy. Their conclusion regarding the duration of pain being less after guillotine agrees with our published audit figures. They found a mean duration of pain for 2.3 days after guillotine tonsillectomy and 5.7 days after dissection tonsillectomy. Our figures are 3.6 and 6.9, respectively [12]. Our study specifically measures pain as objectively as possible by a trained independent observer using a structured measuring tool. This also has the advantage in that we gained a meaningful measure of the severity of pain that arises despite the use of a comprehensive analgesic regimen. Post-tonsillectomy pain is notoriously difficult to manage and often underestimated [2]. Our results support that statement. In our study we used a comprehensive combination of analgesia through different routes. NSAIDS combined with paracetamol are thought to be effective for patients following tonsillectomy [13,14]. We also used per-operative fentanyl which has been shown to enhance the post-operative analgesia attained using NSAIDS [15]. Despite this, 52 and 19% in the two groups of children are in moderately severe or severe pain and require rescue analgesia
at some point during the first 24 post-operative hours. On the basis of our findings we advocate tonsillectomy by guillotine in children and the less pain that arises within the first 24 h may be particularly important if performing tonsillectomy as a day-case procedure. The guillotine method has fallen into disrepute because of an association with haemorrhage and incomplete tonsil excision, leaving remnants behind. However, with time for hemostasis at the end of the procedure, and with the design of the Popper’s guillotine (where the tonsil capsule is crushed before being guillotined), higher hemorrhage rates have not been observed [7]. There is also no higher rate of tonsil remnants [8]. We find occasionally in children that it is not possible to introduce the tonsil into the guillotine on account of excessive fibrosis around the tonsil. In these cases a dissection technique has to be followed. For this reason, we find the guillotine technique not suitable for adult tonsillectomies. However with most children there is no problem and complete excision takes place. Even when the tonsils appear to be buried, by pushing them through the guillotine via the anterior faucal pilla, the tonsil is, in effect, being dissected as it enters the guillotine in this way. Clearly there is a learning curve in using the guillotine. In addition to being less painful, the technique is quicker and with less per-operative blood loss than dissection [8]. A criticism of the study is the lack of allocation by randomisation between the two groups. Nevertheless the general population from which the patients were drawn, the anaesthetic protocol, operating theatre and ward staff and the post-operative nursing care were the same for both groups.
5. Conclusion Tonsillectomy by guillotine results in less pain in the first post-operative 24 h. Post-operative pain, despite a comprehensive analgesic regimen remains a significant problem following tonsillectomy.
J.J. Homer et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 25–29
29
[8] M. Wake, P. Glossop, Guillotine and dissection tonsillectomy compared, J. Laryngol. Otol. 103 (1989) 588 – 591. [9] G.S. Weligodapola, Comparative study of tonsillectomy performed by guillotine and dissection methods, J. Laryngol. Otol. 97 (1983) 605 – 606. [10] R. Qureshi, O.R. Buckingham, A pain assessment tool for all children, Paediatr. Nursing 6 (1994) 11 – 13. [11] Cowan, D.L., Hibbert, J., 1997. Tonsils and adenoids. In: Kerr, A.G. (Ed.), Scott-Browns’s Otolaryngology. 6th edn. Butterworth-Heinemann, Oxford, 6/18/9 – 11. [12] P. Semple, J. Swallow, L. Knight, Post-tonsillectomy: ‘a pain at home’, Yorkshire Med. 10 (1997) 30 – 32. [13] M.E. Bone, D. Fell, A comparison of rectal diclofenac with intramuscular papaveretum or placebo for pain relief following tonsillectomy, Anaesthesia 43 (1988) 277 – 280. [14] C.H. Watters, C.C. Patterson, H.M.L. Matthews, W. Campbell, Diclofenac sodium for post-tonsillectomy pain in children, Anaesthesia 43 (1988) 641 – 643. [15] J.E. Mendham, S.J. Mather, Comparison of diclofenac and tenoxicam for post-operative analgesia with and without fentanyl in children undergoing adenotonsillectomy or tonsillectomy, Paediatr. Anaesth. 17 (1996) 517 – 519.
References [1] McKerrow, W.S., 1998. Tonsillectomy and adenoidectomy. In: Statements of Clinical Effectiveness. British Association of Otorhinolaryngologists Head and Neck Surgeons, pp. 49 – 61. [2] H.M. Myatt, R.A. Myatt, The development of pediatric quality of life questionnaire to measure post-operative pain following tonsillectomy, Int. J. Pediatr. Otolaryngol. 44 (1998) 115 – 123. [3] A.K. Tewary, Day-case tonsillectomy: a review of the literature, J. Laryngol. Otol. 107 (1993) 703–705. [4] M.P.J. Yardley, Tonsillectomy, adenoidectomy and adenotonsillectomy: are they safe day case procedures?, J. Laryngol. Otol. 106 (1992) 299–300. [5] M.B. Pringle, E. Cosford, P. Beasley, A.P. Brightwell, Day-case tonsillectomy — is it appropriate?, Clin. Otolaryngol. 21 (1996) 504–511. [6] Blair, R.L., McKerrow, W.S., Carter, N.W., Fenton, A., 1996. The Scottish tonsillectomy audit. J. Laryngol. Otol. 110(Suppl. 20). [7] C. Roberts, S. Jayaramachandran, C.H. Raine, A prospective study of factors which may predispose to post-operative tonsillar fossa haemorrhage, Clin. Otolaryngol. 17 (1992) 13 –17.
.