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A comparative study of tonsillectomy done under general anaesthesia versus local anaesthesia.

INTRODUCTION

Tonsillectomy is one of the most common surgical procedures performed worldwide. Tonsillectomy was first attempted by a Roman aristocrat Aulus Cornelius Celsus. (1) (25 BC--50 AD) whereby using the finger he separated the tonsil from the underlying tissue. Thereafter, some form of morcellation with only partial removal of tonsils was practiced over centuries. The first tonsillectomy was described by Caque of Rheims. (2,3) in 1757. Galen was the first to advocate the use of surgical instrument known as snare.

Early in the twentieth century surgical removal of the tonsils became very popular and significant cures for various respiratory or systemic diseases were attributed to the procedure. This popularity reached the peak in early 1930s, following which a decline in the procedure took place. Although enthusiasm for tonsil surgery has been varied since then, tonsillectomy and adenoidectomy still remain the most common surgical procedure performed.

Under most circumstances, general anaesthesia is safe and is invariably necessary in children. Adult tonsillectomies, although less frequent, can be done under general or local anaesthesia. Many otolaryngologists reject the idea of local anaesthesia for tonsillectomy for fear of patient discomfort and consequent dissatisfaction. Moreover, there is an unnecessary concern over airway and haemostatic control with local tonsillectomy. However local anaesthesia is generally regarded as a safer procedure than general anaesthesia. (3)

In India tonsillectomy is generally done under general anaesthesia, but local anaesthesia is a better alternative in cooperative teenage and adult patients. Chronic tonsillitis remains the single most common indication for tonsillectomy. (4)

Dissection and snare method is widely practiced and the safest method of tonsillectomy. However, other methods have been introduced over years like electrocautery, laser, coblation, bipolar scissors tonsillectomy and radiofrequency ablation. Although, these alternate methods have an advantage of decreasing the blood loss and postoperative pain, they are side-lined because of economic considerations.

The objective of this retrospective study is to compare the results of general versus local anaesthesia in 981 tonsillectomies performed with respect to duration of surgery, blood loss and pain score.

MATERIALS AND METHODS

The study conducted between May 2012 and June 2015 focused on 981 patients during the period of 37 months. Patients with age ranging from 18 yrs. to 45 yrs. were included. Tonsillectomy done for patients with chronic tonsillitis only were included. Patients younger than 18 yrs. and more than 45 yrs. of age, tonsillectomy done for other causes and patients with disorders of haemostasis or hypersensitivity to local anaesthetics and with history of epilepsy, diabetes, hypertension, heart disease, neurological disease, thyroid toxicity and asthma were excluded. This study was designed as a retrospective study to compare tonsillectomy under general anaesthesia with local anaesthesia. Ethical Committee clearance was obtained from the institution.

The study included 981 pts. who underwent tonsillectomy under general and local anaesthesia. The youngest patient was 18 yrs. female and the oldest was a 44 yrs. male. Male patients were 538 and females were 443. GA tonsillectomy was done in 496 patients and LA tonsillectomy done in 485 patients. Males were 211 and females were 285 in GA tonsillectomy. Males were 327 and females were 158 in LA tonsillectomy.

All apprehensive and uncooperative patients were operated under general anaesthesia and rest under local anaesthesia. Patients with acute tonsillitis were given 2 weeks of antibiotics before admission. A detailed history was taken. Baseline investigations included complete blood count with coagulation profile (Platelet count, prothrombin time and partial thromboplastin time), ECG, chest X-ray, Blood sugar and serum creatinine were analysed. The procedure was explained to the patient and a written consent was obtained. All patients posted for general anaesthesia underwent a detailed pre-anaesthetic evaluation.

The position of Rose is ideal for tonsillectomy, because it allows protection of the airway by a decrease in venous pressure and better muscle tone for good constriction of the blood vessels. (5) All our patients in the study underwent intervention in this position. General anaesthesia was given with nasotracheal or orotracheal intubation. Local anaesthesia was premedication constituting 1 mL of atropine and 1 mL of pentazocine diluted in 10 cc of distilled water and given IV 10 minutes before the procedure. Lignocaine spray of 10% was used 5 minutes before local infiltration. Equal amounts (7-10 mL) of local anaesthesia was infiltrated to the upper, middle and lower poles of the tonsils and to the posterior arch. Local anaesthetic used was (1:200000) lidocaine with adrenaline. Subcapsular removal of tonsils with ligation of bleeders with 2-0 thread was done.

The operative time in case of general anaesthesia was taken from time of induction to the time of getting back the swallowing reflex. In local anaesthesia, it was from the time of infiltration to the time the patient sat up and shifted to trolley. Intraoperative bleed. (6) was calculated by 2 methods--swab weighing technique and blood volume studies. In swab weighing method, before starting the surgery cotton and ribbon gauze was taken, weighed and sterilized. The weight was always kept constant at 20 g. After the surgery, all the soiled gauzes and cotton balls were weighed using a physical balance. The difference in weights is the weight of blood lost in cotton and gauze. This was converted into millilitres by dividing the weight by specific gravity, which is 1.055. In blood volume studies, the suction bottle was cleaned and emptied completely before starting the operation. A known quantity of saline (150 mL) was taken in the bowl and used for intermittent suction to prevent blockage of the suction tube. During surgery, all the blood lost was collected in the suction bottle. The quantity was then measured by pouring it into the measuring cylinder. Pain sensations. (7) were recorded by visual analog scale (VAS) at 6, 10, 18 and 24 hours after surgery and the average is recorded.

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Postoperatively, nil per oral was maintained for 2 hours in local anaesthesia group and 4 hours for general anaesthesia group. Intramuscular non-steroidal anti-inflammatory drugs and oral analgesics were given for pain relief. General anaesthesia group were discharged on 3rd postoperative day while local anaesthesia group were discharged on 2nd day.

RESULTS

No unusual complications were encountered in the present study. In general anaesthesia patients, mean duration of surgery in males was 50.60 mins and in females was 50.45 mins. Mean blood loss in males was 44.56 mL and in females was 45.69 mL. The VAS scores in males was 4.28, 4.11, 3.67 and 3.32 at 6, 10, 14 and 18 hours. The VAS scores in females was 4.58, 4.36, 4.10 and 3.74 at 6, 10, 14 and 18 hours respectively (Table 1).

In local anaesthesia group, mean duration of surgery in males was 34.45 mins and in females was 32.21 mins. Mean blood loss in males was 28.45 mL and in females was 29.98 mL. The VAS scores in males were 2.43, 3.51, 3.29 and 3.85 at 6, 10, 14 and 18 hours respectively. The VAS scores in females were 2.15, 3.61, 3.23 and 3.47 at 6, 10, 14 and 18 hours respectively (Table 2).

A significant reduction in duration of surgery, blood loss and VAS scores were seen in local anaesthesia group compared to general anaesthesia group.

In the postoperative period, the incidence of immediate complications reactionary haemorrhage (0.2%), clot in tonsillar fossa (0.1%), sore throat and otalgia were seen in both the groups. Temporomandibular joint pain was present in 0.4% of patients aged >40 years and was more common in females. Nausea and vomiting was more in the general anaesthesia group. Secondary haemorrhage was not seen in both the groups in the present study. Uvular oedema (7.5%) was the only late complications seen in both the groups.

DISCUSSION

Palatine tonsils. (8) are the largest member of the inner Waldeyer's ring. It is almond shaped and lie on either side of the oropharynx. The gland first appears at the fourth month of intrauterine life and reaches its fullest development from 5 to 7 years of age, at which time it begins to atrophy and if it has not been diseased should have wholly disappeared by the time the child is 15 years old. This gland is only a part of the lymphoid tissue derived from the hypoblast. Developmentally, tonsils arise from the ventral portion of the second pharyngeal pouch, i.e. ideally named as sinus tonsillaris. The trace of this sinus is present in tonsil as supratonsillar cleft. The medial surface of the tonsil is free and faces the oropharynx. It is covered by non-keratinizing stratified squamous epithelium, which is continuous with that of the lining of the oropharynx. A triangular fold of mucous membrane extends back from the palatoglossal fold to cover the anteroinferior part of the tonsil. This fold of mucous membrane is known as plica triangularis. In childhood, this fold is usually invaded by lymphoid tissue and becomes incorporated into the tonsil. A semilunar fold of mucous membrane passes from the upper aspect of the palatopharyngeal arch towards the upper pole of tonsil, thus separating it from the base of the uvula.

These Waldeyer's rings constitute an antigen sampling centre where the extraneous antigens are caught and sampled stimulating the immune mechanism. Antigens from inspired air are trapped by the adenoid and the tubal tonsils. These antigens in turn stimulate release of immunoglobulins by the B lymphocytes. To facilitate exposure and trapping of antigens from ingested food, the mucosa covering the palatine tonsils are thrown into numerous crypts about 18-20 in each tonsil. These crypts serve to increase the surface area of mucosa covering the tonsil.

With advances in anaesthetic techniques, risks are lowered thereby increasing the cost of surgery. Hence, local tonsillectomy is a better alternative in co-operative patients with an added advantage of cost effectiveness and greater patient acceptance. The procedure aimed at complete removal of tonsils with minimal blood loss and trauma to adjacent tissue in turn reducing the blood loss and post-operative pain. A comparison with respect to blood loss, duration of surgery, morbidity and patient satisfaction was made. Local tonsillectomy proved less costly with significant reduction of blood loss and lessened duration of surgery. However, there was no significant difference in incidence of post-operative complications and morbidity.!3) As post-operative pain played an important role in early recovery of the patient, pain was managed by infiltration of local anaesthetic into the tonsillar fossa during intraoperative period and intramuscular nonsteroidal anti-inflammatory drugs and oral analgesics in postoperative period.

Normal adult mouth opening ranges between 23 and 71 mm measured between the incisor teeth. The Maximal InterIncisal Distance (MID), i.e. linear mouth opening, is generally used as a measure for TMJ mobility and is significantly related to condylar mobility. TMJ symptoms encountered in the present study was 0.4% limited to patients aged >40 yrs. This may be because of the fact that deployment of the mouth gag in this study only marginally increased the MID, imparting no additional stress to the temporo-mandibular joint. Kundi NA. (9), Mehmood T et al concluded that the duration of mouth gag application should be reduced to cause less TM joint pain and trismus in early postoperative period in tonsillectomy and mean time of application of Boyle's Davis mouth gag was 47 [+ or -] 12 minutes. In patients with duration of application of mouth gag more than 55 minutes, the degree of trismus and pain was severe in all the cases postoperatively. In the present study, as the operative time in the general anaesthesia group was 50.52 mins and local anaesthesia group was 33.33 mins, the duration of mouth gag application is relatively less in both the groups.

As post-tonsillectomy haemorrhage is a dreadful complication, mastery of per-operative and post-operative bleeding is decisive for the success of the tonsillectomy performed under General or Local anaesthesia. (5)

Bredenkamp. (1) JK et al in 64 local tonsillectomies performed concluded that the procedure under local anaesthesia has minimal morbidity, complications and good patient satisfaction with little blood loss (42 mL in local anaesthesia group over 198 mL in general anaesthesia group) in his 7 yrs. study.

Sudhir M Naik . (10) concluded that tonsillectomy under local anaesthesia is good alternate for the procedure under general anaesthesia with limited resources and morbidity and complications with little blood loss in cooperative adults, as it has significant difference in duration of surgery blood loss and Visual Analog Scale (VAS) pain scores. Our study has also shown that tonsillectomy under local anaesthesia has less severe pain, minimal morbidity and minimum rate of unusual complications. So it coincides with the above mentioned results.

McClairen. (3) et al, in their study of 73 patients found local tonsillectomy to be of significantly less duration 24 mins for LA tonsillectomy and 50 mins for GA tonsillectomy, less intraoperative haemorrhage--9cc in LA group and 200 cc in GA group, less costly and no significant difference in postoperative haemorrhage or patient acceptance.

Agren K. (11) et al concluded that in 38 tonsillectomies done under local anaesthesia, in suitable patients is a safe alternative to tonsillectomy under general anaesthesia and that considerable resources can be saved if the operation is performed with local anaesthesia.

Sacko H B. (12) et al in his study of 166 patients concluded that tonsillectomy under local anaesthesia is well tolerated by patients, adolescents and adults. The success of such intervention requires in addition to the surgical technique proper in the hands of a well-trained surgeon, premedication quiescent to minimize the emotional factor often nonnegligible in the patient during the intervention and haemorrhagic risks. With local anaesthesia, the operation required less time.

Pekkarinen. (13) et al reported that tonsillectomy under local anaesthesia was also a cardiologically safe procedure; however, tonsillectomy under local anaesthesia should always be performed in a surgical suite under the supervision of an anaesthetist as unexpected intraoperative haemorrhage due to vascular anomalies might require intervention under general anaesthesia.

CONCLUSION

The Results of this Study concludes that Tonsillectomy under Local Anaesthesia

1. Well tolerated by co-operative adolescents and adults.

2. The duration of surgery, blood loss and pain scores are less in local anaesthesia compared to general anaesthesia.

3. Patient satisfaction and acceptance is also greater in case of local anaesthesia group.

4. Cost effective and can be done as a day care surgery.

The surgeon must consider all the factors in a patient before choosing the type of anaesthesia best suited for each case.

REFERENCES

(1.) Sheikh MS, Akhtar M, Shafique MA. Tonsillectomy under local anaesthesia: is it safe, feasible and practicable? Experience at tertiary care hospital. JSZMC 2014;5(4):733-6.

(2.) Brendenkamp JK, Abemayor E, Wackym PA, et al. Tonsillectomy under local anaesthesia: an age and effective alternative. AM J Otolaryngol 1990;11(1):18-22.

(3.) McClairen WC, Strauss M. Tonsillectomy: a clinical study comparing the effects of local versus general anesthesia. Laryngoscope 1986;96(3):308-10.

(4.) Bolisten TA, Upton JJ. Infiltration with lignocaine and adrenaline in adult tonsillectomy. J Laryngol Otol 1980;94(11):1257-9.

(5.) Bluestone CD. Status of tonsillectomy and adenoidectomy. Laryngoscope 1977;87(8):1233-43.

(6.) Prasad KC, Prasad SC. Assessment of operative blood loss and the factors affecting it in tonsillectomy and adenotonsillectomy. Indian J Otolaryngol Head Neck Surg 2011;63(4):343-8.

(7.) Gupta AK, Gupta S, Meena DS, et al. Post-tonsillectomy pain: different modes of pain relief. Indian J Otolaryngol Head Neck Surg 2002;54(2).

(8.) Balasubramanian T. Tonsillectomy in the: short topics in otolaryngology. drtbalu's Otolaryngology on line, 2007.

(9.) Kundi NA, Mehmood T, Abid O. Application of mouth gag and temporomandibular joint pain and trismus in tonsillectomy. J Coll Physicians Surg Pak 2015;25(4): 268-70.

(10.) Naik SM, Naik SS, Ravishankara S, et al. Advantages of tonsillectomy done under local anaesthesia compared to general anaesthesia in adults. Int J Head Neck Surg 2013;4(1):13-8.

(11.) Agren K, Engquist S, Danneman A, et al. Local versus general anaesthesia in tonsillectomy. Clin Otolaryngol Allied Sci 1989;14(2):97-100.

(12.) Sacko HB. Tonsillectomy under local anaesthesia in mali. Otolaryngology Online Journal 2015;5(2):ISSN:22500359.

(13.) Pekkarinen H, Karja J. Results of long-term ECG monitoring in patients submitting to tonsillectomy under local anaesthesia. J Laryngol Otol 1982;96(8):725-30.

Financial or Other, Competing Interest: None.

Submission 31-05-2016, Peer Review 24-06-2016, Acceptance 30-06-2016, Published 07-07-2016.

Corresponding Author: Dr. P. S. Maradesha, Assistant Professor, Department of ENT, K. R. Hospital, Mysore.

E-mail: dr.mardesh@gmail.com

DOI: 10.14260/jemds/2016/844

P. S. Maradesha [1], Samatha K. J [2], M. K. Veenapani [3]

[1] Assistant Professor, Department of ENT, K. R. Hospital, Mysore.

[2] Senior Resident, Department of ENT, K. R. Hospital, Mysore.

[3] Professor and HOD, Department of ENT, K. R. Hospital, Mysore.
Table 1: Average Scores of Parameters in General Anaesthesia Patients

                       General Anaesthesia

             Duration    Blood Loss      VAS Score
            of Surgery

              50.60       44.56 mL     6 hours- 4.28
Males-         mins                    10 hrs.- 4.11
211                                    18 hrs.- 3.67
                                       24 hrs.- 3.32

              50.45       45.69 mL     6 hours- 4.58
Females-       mins                    10 hrs.- 4.36
285                                    18 hrs.- 4.10
                                       24 hrs.- 3.74

Table 2: Average Scores of Parameters in Local Anaesthesia Patients

                       Local Anaesthesia

             Duration    Blood Loss      VAS Score
            of Surgery

Males-      34.45 mins    28.45 mL     6 hours- 2.43
327                                    10 hrs.- 3.51
                                       18 hrs.- 3.29
                                       24 hrs.- 3.85

Females-    32.21 mins    29.98 mL     6hours- 2.15
158                                     10hrs- 3.61
                                        18hrs- 3.23
                                        24hrs- 3.47
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Author:Maradesha, P.S.; Samatha, K.J.; Veenapani, M.K.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Jul 7, 2016
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