The effects of a preoperative steroid/anesthetic injection on post-tonsillectomy pain - Original Article

Ear, Nose & Throat Journal, April, 2003 by Timothy M. Maj. Cupero, Sam Y. Capt. Kim, Andrew B. Silva

Abstract

We conducted a placebo-controlled, single-blind study to determine the efficacy of a local preoperative injection of a steroid/anesthetic combination in preventing posttonsillectomy pain. We randomized 21 adults to receive either triamcinolone/bupivacaine on the left side and saline on the right or vice versa. Injections were administered in the area of the tonsillar pillars following intubation and prior to tonsillectomy. Based on the "generalized estimating equations" model of statistical analysis, we found no significant difference in the degree of postoperative pain between the active-treatment and control sides.

Introduction

Otolaryngologists have dealt with the issue of postoperative tonsillar pain since the earliest days of the procedure. Postoperative pain can have a detrimental effect on patients and can increase the risk of postoperative complications. The consequences of postoperative pain include dehydration, the need for narcotic medication, a higher risk of bleeding, and a greater number of missed school or work days. (1)

The search for effective pain prevention is valid. Although many protocols have been tried, no one standard for controlling postoperative pain currently exists. Although electrocautery is the most widely used technique, many newer surgical modalities have been developed in the hope of not only decreasing postoperative pain, but in shortening operative time, as well. Pharmacologic and other adjuvant strategies have also been extensively investigated with the goal of achieving better postoperative pain control. Protocols involving steroids, (2-10) anesthetics, (9-13) antibiotics, (9,10,14) catecholamines, (10,11,15) and nonsteroidal anti-inflammatory drugs (16) have been attempted with varying results. Even the use of radiation has been reported. (17)

Previous experience with steroids has not been associated with an increase in complications during post-tonsillectomy recovery, and these agents are commonly used in the otolaryngology community. (2,3,6,7,9) To our knowledge, no study of local preoperative steroid/anesthetic injections for postoperative tonsillectomy pain has been previously described in the literature. In this article, we describe our study of this regimen.

Patients and methods

After receiving approval from our hospital's internal review board, we began recruiting adult candidates for our study. Each candidate provided a thorough history and underwent a physical examination prior to study entry. All candidates were also evaluated with respect to our study's inclusion and exclusion criteria. Inclusion criteria included age between 18 and 65 years and the presence of recurrent tonsillitis (defined as at least seven infections in 1 year, at least five in 2 consecutive years, or at least three per year for 3 consecutive years), asymmetric tonsils, or tonsillar hypertrophy. Exclusion criteria included the presence of diabetes, an episode of peritonsillar abscess or tonsillitis during the preceding 2 weeks, surgery within the previous 2 weeks, the current use of a systemic steroid, a known hypersensitivity to either of the two drugs used in this study (triamcinolone and bupivacaine), and the presence of peptic ulcer disease.

Following our initial screening, 21 patients met the eligibility requirements for our study. They were randomized on the basis of their Social Security numbers to receive either triamcinolone/bupivacaine on the left side and saline on the right or vice versa. All patients were blinded to the protocol used in their particular case. Each tonsillectomy was performed by one of two surgeons. The two surgeons had similar levels of experience, and both used electrocautery for tonsil removal. Adenoidectomy was not performed.

The study medication was a mixture of 1.5 ml of triamcinolone (at 40 mg/ml) and 1.5 ml of plain bupivacaine (at 0.25%) for a total of 3 ml. After intubation and just prior to tonsillectomy, the study mixture was injected as follows: 1 ml in the inferior pole, 1 ml in the superior pole, and 1 ml just lateral to the tonsillar capsule midway between the two poles. The contralateral side was then injected with a similar amount of normal saline in the same locations. No intravenous steroids were administered during or after the procedure.

During the first 10 days postoperatively, patients were asked to use a visual analog scale to self-evaluate the degree of pain they experienced on each side (figure 1). Once these scales were returned to us, the results were compiled and numerical values were assigned to the responses for statistical analysis.

Results

Five of the 21 patients did not return their scales and were excluded from further study. Among the remaining 16 patients--nine women and seven men, aged 19 to 54 years (mean: 27)--six (37.5%) noted a subjective benefit on the active-treatment side. Three patients felt that their pain was worse on the active-treatment side; however, two of these patients had previously experienced peritonsillar abscesses, and their pre-existing scar tissue made the dissection on the study side more difficult. Overall, we conclude that our method of injecting a preoperative mixture of a steroid and a local anesthetic failed to show any significant alleviation of postoperative pain.