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Control of post operative pain by pre- tonsillectomy peritonsillar infiltration.

INTRODUCTION & HISTORY: Pain is a highly unpleasant sensory and emotional experience and postoperative pain control in children is a big challenge for their inability to express and react. In the past two decades, there has been a considerable progress in the understanding of children's perception of pain and responses to pain and various pharmacological agents and analgesic delivery to avoid under treatment of pain in children. A parallel noteworthy advancement has occurred in the knowledge of anatomy, physiology and pharmacology of regional anesthetic techniques. Some of these techniques are now an integral part of perioperative and procedure- related pain management in all ages, in part because of a greater concern about postoperative pain management in patients and in part because of technical advances in equipment to perform the blocks. Tonsillectomy is a very common day care procedure that is associated with significant postoperative pain. This pain has traditionally been treated with opioid analgesics and non- steroidal anti-inflammatory drugs: however, these agents are associated with increased risks to respiratory depression and postoperative bleeding, respectively. Doshi J 2008 et al. (1)

AIMS & OBJECTIVES:

1. To Provide Post Tonsillectomy Analgesia to patients.

2. To evaluate the post-operative analgesic efficacy of pre incisional peritonsillar (PT) infiltration using various agents.

3. To evaluate the effect of various agents infiltration on start of oral intake and discharge from the hospital after tonsillectomy.

4. To investigate the possibility of any complication in relation to drugs infiltration into the peritonsillar Fossa.

Grades of Tonsillar Hypertrophy James Chan (2004). (2):

Standardized tonsillar hypertrophy grading scale:

* (0+) Tonsils are entirely within the tonsillar Fossa.

* (1+) Tonsils occupy less than 25 percent of the lateral dimension of the oropharynx as measured between the anterior tonsillar pillars.

* (2+) Tonsils occupy less than 50 percent of the lateral dimension of the oropharynx.

* (3+) Tonsils occupy less than 75 percent of the lateral dimension of the oropharynx.

* (4+) Tonsils occupy 75 percent or more of the lateral dimension of the oropharynx.

INDICATIONS and CONTRAINDICATIONS:

INDICATIONS: Absolute Indications:

* Respiratory obstruction.

* Huge hypertrophy causing difficulty in feeding.

* Sleep apnea syndrome.

Relative Indication:

* Peritonsillar abscess.

* Chronic tonsillitis.

* Failure of medical treatment to reduce the size.

* More than 3-4 acute episodes in per year.

* Acting aseptic focus for rheumatic heart disease, glomerulonephritis, arthritis etc.

* Primary tuberculosis of the tonsil.

* Diphtheria carrier.

* Tumor of tonsils.

* Tonsillar cyst, tonsillolith, embedded FB in tonsils etc.

* Peritonsillar abscess.

Surgical Approaches:

* Elongated styloid process.

* Glossopharyngeal neurectomy.

* As a part of Uvulo- palato- pharyngo- plasty (UPPP).

CONTRAINDICATIONS:

* Active infection/Acute exacerbation, Aneurysm of internal carotid artery, age below 3 years, active menstruation.

* Bleeding/Clotting disorders.

* Cervical spine pathology.

* Diphtheritic tonsillitis,

* Drugs-aspirin, oral contraceptives etc.

* Endemic of polio.

* Failure to control systemic diseases like hypertension, diabetes, bronchial asthma, LRTI etc.

MATERIAL & METHODS: After approval of the study protocol by the local Ethical Committee and obtaining fully informed written consents, 60 patients assigned for tonsillectomy enrolled in the study of age group 5 to 35 yrs. The study conducted at Department of Otorhinolaryngology, MBS Hospital Kota Rajasthan from Dec. 2010 to Oct. 2012. Patients with history of bleeding diathesis allergy to study drugs, or tonsillar abscesses excluded from the study.

Patients randomly divided into 6 equal study groups (n=10); Group I (Negative control group) included patients assigned to receive PT saline infiltration as placebo, Group II (Positive control group) included patients assigned to receive xylocaine (1%) PT infiltration. Group III included patients assigned to receive tramadol (2mg/kg) PT infiltration, Group IV included patients assigned to receive ketamine (0.5mg/Kg) (3) PT infiltration, Group V received combination of Bupivacaine (5mg/ml) with Tramadol (2mg/kg), Group VI received Bupivacaine (5mg/ml) with Ketamine (0.5mg/Kg). All medications prepared as 2ml in volume and injected as 1ml per tonsil 3 min. prior to incision (Pre-incisional).

All study patients premedicated with midazolan intravenously before the procedure and received nalbufine i.v. immediately after induction of general anesthesia.

A standard anesthetic protocol was constructed for all patients. The protocol consisted of the following;

Premeditation: Pethedin 1mg/kg intramuscular, 1 hour preoperatively

OPERATIVE TECHNIQUES: Tonsillectomy operation performed by dissection method. Before making incision, infiltration of tonsillar bed through ant. Pillar with various analgesic agents likes xylocaine, Ketamine. Tramadol & Placebo (Normal Saline), bupivacaine with tramadol/ketamine as their combination (Regimen).

OBSERVATION AND RESULTS: Patients randomly divided into 6 equal study groups (n=10); Group 1 (Negative control group) included patients assigned to receive PT saline infiltration as placebo; Group 2 (Positive control group) included patients assigned to receive xylocaine (1%) PT infiltration. Group 3 included patients assigned to receive tramadol (2mg/kg) PT infiltration, Group 4 included patients assigned to receive ketamine (0.5mg/Kg) PT infiltration, Group 5 received combination of Bupivacaine (5mg/ml) with Tramadol (2mg/kg), Group 6 received Bupivacaine (5mg/ml) with Ketamine (0.5mg/Kg):

* Gp1-normal saline.

* Gp2-xylocaine (1%).

* Gp3-tramadol (2mg/kg).

* Gp4-ketamine (0.5mg/kg).

* Gp5-bupivacaine (5mg/ml) with tramadol.

* Gp6-bupivacaine with ketamine.

CONCLUSSION AND SUMMARY: # Preincisional infiltrations of various agents are effective method to reduce post-tonsillectomy pain. This method also effective for earlier start of oral feeding and discharge from the hospital.

# We recommend the routine use of pre incisional peritonsillar infiltration of various agents in all tonsillectomy cases, irrespective of the age of the patient to reduce the post-tonsillectomy pain and other morbidities

SUMMARY: This is prospective, randomized, single blind controlled clinical trial to assess the effect of preincisional peritonsillar infiltration of various agents on pain after tonsillectomy, which was performed on Dec. 2010 till Oct. 2012 in the department of ENT, Govt. Medical College, Kota.

A volunteer sample of 60 patients, aged 5 to 35yrs with history of recurrent or chronic tonsillitis were included in this study and planned for tonsillectomy with or without adenoidectomy Patients were divided into 6 equal study groups (n=10); Group I (Negative control group) included patients assigned to receive PT saline infiltration as placebo; Group II (Positive control group) included patients assigned to receive xylocaine PT infiltration. Group III include patients assigned to receive tramadol (2mg/kg) PT infiltration, Group IV included patients assigned to receive ketamine (0.5mg/Kg) PT infiltration, Group V received combination of Bupivacaine (5mg/ml) with Tramadol (2mg/kg), and Group VI received Bupivacaine (5mg/ml) with Ketamine (0.5mg/Kg).

All medications prepared as 2ml in volume and injected as 1ml per tonsil 3 min prior to incision (Pre-incisional).

Postoperative pain was assessed using OPS and ALDRETE score for severity of pain at different time after the surgery. The time of oral intake start and total admission days after the surgery also were noted.

Comparison of various agents for pain, oral intake and postoperative admission days were noted.

No complication of preincisional peritonsillar infiltration of various agents was seen in this study.

DOI: 10.14260/jemds/2015/1737

ACKNOWLEDGEMENT: Achieving a milestone for any person alone is extremely difficult. However, there are motivators which come across the curvaceous path like twinkling stars in the sky and make our task much easier. It becomes my humble and foremost duty to acknowledge all of them. Words are always deficient to thank my parents Mrs. Dhapu devi, Mrs. Kanta devi and Mr. Khemraj meena also manda devi who have been my inspiration and motivation in all fields of life and without whose guidance, love and blessings, I would have never achieved this stage in my life. No words would be sufficient to express my gratitude to my Wife Deepti Meena and saket karol for sharing the journey of development of this project with me, for her deepest love, for understanding my feelings, for always being on my side in tense moments, for believing in me and for giving me expert feedback and advice.

BIBLIOGRAPHY:

(1.) Doshi J, Damodara M, Gregory S, Anari S (2008)S: Post-Tonsillectomy morbidity statistics: are they underestimated? J Laryngol Otol.;122(4):374-7

(2.) James Chan, Jennifer C Edman, Peter J Koltai. Tonsillar Hypertrophy. Am FAM Physician. 2004:69(5):1147-1155

(3.) Umuroglu T, Eti Z, Ciftci H. Analgesia for adenotonsillectomy in children: A comparision of morphine and ketamine and tramadol. Pediatric Anesth 2004; 14: 568-73

(4.) Aldrete JA (1995): The post-anaesthetic recovery score visited. J Clin Anesth: 7:89-91, 1995.

(5.) Hannallah RS, Broadman LM, Belman B, Abromowitz MD, Estein BS (1987): Comparision of caudal and illioinguinal/illiohypogastric nerve blocks for the control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology; 66: 832-4.
PROFORMA
DEPARTMENT OF E.N.T
MBS & ATTACHETED GROUP OF HOSPITAL & MEDICAL COLLAGE, KOTA

Name.                    Age   Sex   weight
Occupation.
Address.                 DOA   DOO    DOD
Chief Complaints:
Past History:
Personal History.
Family History.
Examination of Nose & throat: Ch. Tonsillitis Yes/No.
Any other important finding.
Routine investigation: Hb, TLC, DLC, BT, CT, ESR, Platelet count,
                       peripheral smear, prothrombin and activated
                       prothrombin time
Complete Urine.

Evaluation of renal and cardiac function if rheumatic disease is
  suspected.
ECG in elderly patients.
Chest X-ray PA view.
X-Ray soft tissue lat. View Nasopharynx
Diagnostic nasal endoscopy for adenoid hypertrophy.
Operative finding.
Post-operative evaluation.

Table 1: Age wise Distribution of patients

    Age        Min.   Max.

    Gp 1        6      35
    Gp 2        5      34
    Gp 3        6      35
    Gp 4        8      33
    Gp 5        10     32
    Gp 6        8      34
All Patients    5      35

Table 2: Sex wise Distribution of patients

    Sex        Male   Female

    Gp 1        8        2
    Gp 2        7        3
    Gp 3        6        4
    Gp 4        5        5
    Gp 5        8        2
    Gp 6        6        4
All Patients    40      20

Table 3: Distribution of patients according to recurrent attack
of Sore throat

Sore Throat    Number of pts.   percentage

    Gp 1             8              80
    Gp 2             7              70
    Gp 3             9              90
    Gp 4             7              70
    Gp 5             8              80
    Gp 6             7              70
All Patients         46            76.6

Table 4: Distribution of patients according to Tonsillar Hypertrophy

Tonsillar Hypertrophy   Number   Percentage

        Gp 1              8          80
        Gp 2              7          70
        Gp 3              9          90
        Gp 4              6          60
        Gp 5              7          70
        Gp 6              8          80
    All Patients          45         75

Table 5: Distribution of patients according to Breathing Difficulty

Breathing Difficulty   Number   Percentage

        Gp 1             0          0
        Gp 2             0          0
        Gp 3             1          10
        Gp 4             0          0
        Gp 5             0          0
        Gp 6             1          10
    All Patients         2         3.33

Table 6: Distribution of patients according to swallowing difficulty

Swallowing Difficulty   Number   Percentage

        Gp 1              1          10
        Gp 2              0          0
        Gp 3              1          10
        Gp 4              1          10
        Gp 5              0          0
        Gp 6              1          10
    All Patients          4         6.66

Table 7: Distribution of patients according to recurrent attack
of Fever

Fever          Number   Percentage

Gp 1           5        50
Gp 2           6        60
Gp 3           5        50
Gp 4           7        70
Gp 5           8        80
Gp 6           6        60
All patients   37       61.6

Table 8: Distribution of patients according to Earache

  Ear pain     Number   Number

    Gp 1         2        20
    Gp 2         1        10
    Gp 3         3        30
    Gp 4         2        20
    Gp 5         2        20
    Gp 6         3        30
All Patients     13      21.6

Table 9: Distribution of patients according to Enlargement of
Jugulodigastric node

Enlarge node   Number   percentage

    Gp 1         2          20
    Gp 2         3          30
    Gp 3         2          20
    Gp 4         3          30
    Gp 5         1          10
    Gp 6         2          20
All patients     13       21.66

Table 10: Distribution of patients according to Ant. Pillar Congestion

Ant. Pillar congestion   Number   Percentage

         Gp 1              4          4
         Gp 2              5          5
         Gp 3              6          6
         Gp 4              4          4
         Gp 5              5          5
         Gp 6              4          4
     All patients          28        46.6

Table 11: Distribution of patients according to Headache

  Headache     Number   Percentage

    Gp 1         1          10
    Gp 2         2          20
    Gp 3         1          10
    Gp 4         1          10
    Gp 5         0          0
    Gp 6         0          0
All patients     5         8.33

Table 12: (b) Distribution of patient's according to Start oral
intake (hrs. up to) post-operatively

Start oral intake   4th    6th    9th    12th
    in (hrs)

      Gp 1           10     20     30     50
      Gp 2           30     40     50     70
      Gp 3           40     50     70     80
      Gp 4           50     60     80     90
      Gp 5           70     80     90     100
      Gp 6           80     90    100     100
  All Patients      46.6   56.6    70    81.6

Table 13: Distribution of patients according to Requirement of 1st
oral analgesic dose post-operatively

1st dose                Hrs.                Mean

  Gp 1          6,5,7,4,5,4,6,5,6,4          5.2
  Gp 2     11,13,12,11,12,13,13,12,11,14    12.2
  Gp 3     15,16,15,16,15,16,16,15,13,16    15.3
  Gp 4     17,16,15,17,16,18,17,18,17,17    16.8
  Gp 5     22,19,22,18,20,21,18,22,19,19     20
  Gp 6     24,23,23,24,21,21,21,22,21,20     22

Table 14: Distribution of patients according to hospital stay
(Hrs.) after tonsillectomy

Hospital             Time(Hrs.)             Mean
  stay

  Gp1      60,72,66,60,72,66,60,72,72,66    66.6
  Gp2      48,60,54,48,54,48,60,54,48,48    52.2
  Gp3      42,48,42,54,48,54,42,48,42,48    46.8
  Gp4      36,42,36,48,54,36,42,36,54,42    42.6
  Gp5      36,24,42,36,24,42,36,42,36,24    34.2
  Gp6      24,36,36,24,24,24,36,24,36,24    28.8

Table 15: Distribution of patients (Average) according to
Aldrete score

Aldrete score   1hr   2hr   6hr   12hr   24hr

     gp1         6     6     6     7      8
     gp2         7     7     8     8      9
     gp3         7     8     8     9      9
     gp4         8     8     9     9      10
     gp5         8     9     9     10     10
     gp6         9    10    10     10     10

Table 16: Distribution of the patients (Average) according to
OPS Score

OPS score   1hr   2hr   6hr   12 hr  24hr

   gP1       7     7     6     6      5
   gP2       6     4     4     3      3
   gP3       5     4     3     3      2
   gp4       3     3     2     0      0
   gP5       3     2     0     0      0
   gP6       2     0     0     0      0


Shamendra Kumar Meena [1], Rajkumar Jain [2], Vijay Kumar Meena [3], Ramraj Meena [4], Muniram Meena [5]

AUTHORS:

[1.] Shamendra Kumar Meena

[2.] Rajkumar Jain

[3.] Vijay Kumar Meena

[4.] Ramraj Meena

[5.] Muniram Meena

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of ENT, Govt. Medical College, Kota.

[2.] Associate Professor, Department of ENT, Govt. Medical College, Kota.

[3.] Associate Professor, Department of ENT, Govt. Medical College, Kota.

[4.] Medical Officer, SWM.

[5.] Medical Officer, Udaipur.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Shamendra Kumar Meena, KR-21, Civil Line, Nayapura, Kota-324001, Rajasthan.

E-mail: shamendra.meena82 @gmail.com

Date of Submission: 26/07/2015.

Date of Peer Review: 04/08/2015.

Date of Acceptance: 21/08/2015.

Date of Publishing: 26/08/2015.
Table: 1 Constituents Parameters of Aldrete Score (4)

 Item / Score                2                           1

 Respiration     Able to breathe deeply &       Dyspnea or limited
                       cough freely                  breathing

Blood Pressure         [+ or -] 20%               [+ or -] 20-49%
                    pre-operative value         preoperative value

   Activity        Able to move 4 limbs        Able to move 2 limbs
                 voluntarily or on command   voluntarily or on command

Consciousness           Fully awake            Arousable on calling
  [O.sub.2]            <92 % on air            >90 % with [O.sub.2]
  saturation                                        supplement

 Item / Score                0

 Respiration               Apnea

Blood Pressure         [+ or -] 50%
                    pre-operative value

   Activity        Unable to move limbs
                 voluntarily or on command

Consciousness         Not responding
  [O.sub.2]           <90% even with
  saturation       [O.sub.2] supplement

Table: 2 Constituents Parameters of OPS Score (5)

Item / Score         0                   1                    2

   Blood       [+ or -] 10 %    >20% pre-operative        >50% pre-
  Pressure     preoperative            value              operative
                   value

   Crying        Not Crying     Crying but responds    Crying and does
                                   to loving care      not respond to
                                                         loving care

  Movement          None              Restless            Thrashing
 Agitation     Asleep or Calm           Mild             Hysterical
  Posture        No Special        Flexing legs        Holding scrotum
                                     and thighs           or groin
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Title Annotation:ORIGINAL ARTICLE
Author:Meena, Shamendra Kumar; Jain, Rajkumar; Meena, Vijay Kumar; Meena, Ramraj; Meena, Muniram
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Aug 27, 2015
Words:2625
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