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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 4  |  Page : 127-132

Nonpharmacological management of posttonsillectomy pain


Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission18-Jul-2021
Date of Decision28-Aug-2021
Date of Acceptance29-Aug-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_33_21

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  Abstract 


Tonsillectomy is a frequently performed surgical procedure by otolaryngologists. Patients' complaints of posttonsillectomy pain are unavoidable. Pain is a significant obstacle for rehabilitation of the patients following tonsillectomy and it influences the duration of the hospital stay and ability to revive for normal activity. The pain following tonsillectomy often affects oral intake, ability to return to their daily world, and discharge from the hospital. The relief of posttonsillectomy pain remains challenging and even controversial. Pain is common and intense in the posttonsillectomy period. Posttonsillectomy is one of the most common unpleasant side effects of tonsillectomy. There are several techniques and treatment methods available to get relief from posttonsillectomy pain. Although this area has received little scientific attention until now, the desire for alternatives to drug-based treatment for posttonsillectomy pain has continued to develop in recent years. Currently, pain following the posttonsillectomy period continues to be a highly debated issue and an area of active research. Throat pain in the posttonsillectomy period can result in significant morbidity among patients. There are different pharmacologic agents available; each one has its risk profile and side effects when used for controlling posttonsillectomy pain. However, here this reviews article discusses important nonpharmacological agents for the management of posttonsillectomy pain. This article reviews the epidemiology, pathophysiology, and details of nonpharmacological agents used for controlling posttonsillectomy pain.

Keywords: Analgesics, nonpharmacological treatment, posttonsillectomy pain, tonsillectomy


How to cite this article:
Swain SK. Nonpharmacological management of posttonsillectomy pain. Saudi J Otorhinolaryngol Head Neck Surg 2021;23:127-32

How to cite this URL:
Swain SK. Nonpharmacological management of posttonsillectomy pain. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jan 21];23:127-32. Available from: https://www.sjohns.org/text.asp?2021/23/4/127/328728




  Introduction Top


Tonsillectomy is a commonly performed surgical surgery, especially among children. Posttonsillectomy pain is a common side effect of the procedure, and it can be severe and continue for up to 10 days.[1] Pain is an unwanted and unpleasant emotional and sensory experience found in actual or potential tissue injury. Patients, particularly children may produce restlessness or crying due to pain, hunger, or fear after surgery, particularly tonsillectomy. A guideline of French health product safety agency in 2013 limited the market authorization for the use of codeine for children over 12 years of age in case of failure of paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) and contraindicated in case of tonsillectomy and adenoidectomy.[2] As a result, the therapy options for posttonsillectomy discomfort have been limited, particularly in children. Despite the availability of a variety of medications, posttonsillectomy pain persists in the postoperative period. Many unwanted side effects, such as drug intolerance, allergies, drug resistance, or drug apprehension, further complicate the situation. Due to significant posttonsillectomy pain, oral intake of food and beverages may be limited to the point where some patients become dehydrated.[3] Insufficient pain management following tonsillectomy may result in secondary hemorrhage.[3] Hence, there are many alternative therapies are currently available to reduce posttonsillectomy pain and increase patient compliance. This review article describes the details of epidemiology, pathophysiology, and nonpharmacological therapy used for controlling posttonsillectomy pain.


  Methods of Literature Search Top


We performed a literature review of the management of posttonsillectomy pain in patients consisting of a database of Pub Med, Medline, Scopus, and Google scholar search with terms posttonsillectomy pain, management of posttonsillectomy pain, the pathophysiology of posttonsillectomy pain, and nonpharmacological treatment used for posttonsillectomy pain. We reviewed different current articles published in national and international journals. All the articles were read and analyzed, with relevant data being extracted. A flowchart of the selected articles is in [Figure 1]. There 82 abstracts selected through PubMed, Scopus, Google Scholar, and Medline databases with the word posttonsillectomy pain and nonpharmacological management of posttonsillectomy pain. However, there are 34 abstracts of non-English, management of the posttonsillectomy pain other than nonpharmacological treatment and review articles with no primary research data excluded. This manuscript reviews the details of nonpharmacological management of posttonsillectomy pain its epidemiology, pathophysiology, and nonpharmacological treatment used for posttonsillectomy pain. This review article surely makes a baseline from where further prospective studies can be designed for the nonpharmacological treatment for posttonsillectomy pain which can help to prevent this morbid clinical entity.
Figure 1: Flow chart for methods of literature search

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Epidemiology

Approximately 80,000 tonsillectomies are performed every year in England alone.[4] One study showed that 250,000 adenotonsillectomy were performed in the United States every year.[5] As per data from the Centers for Disease Control and Prevention, over 737,000 ambulatory tonsillectomies were performed in the United States in 2006.[6] A study from Denmark showed 153,212 patients underwent tonsillectomies with 84,831 females and 68,381 males during 1980–2001 where the age-specific incidence of tonsillectomy peaked at the age of 4 years for both boys and girls with 9.7 and 6.9 tonsillectomies/1000 person/year, respectively.[7] There has been written about the benefits of tonsillectomy in respect to postoperative improvement of the quality of life and behavior of the patient. Tonsillectomy is one of the most common surgeries done by otolaryngologists which may cause severe pain following tonsillectomy.[8] Posttonsillectomy pain is an expected sequel of this procedure which typically lasts from 7 to 10 days.[8] The post-tonsillectomy may be moderate to severe in intensity. Some patients with posttonsillectomies often need readmission to the hospital for the management of their pain along with management of the dehydration due to poor oral intake of fluids because of such pain.[9]

Pathophysiology for posttonsillectomy pain

The palatopharyngeus, palatoglossus, and superior constrictor of pharyngeus are all associated with the tonsillar fossa. The tonsillar innervation is mainly from the tonsillar branch of the glossopharyngeal nerve and small contribution from the lesser palatine nerve.[10] These neural branches form the nervous plexus in the peritonsillar space. Surgical intervention at the peritonsillar space may affect the neural plexus. After tonsillectomy, the medial surfaces of these muscles are exposed. This situation affects the muscles directly by the surgical trauma or indirectly by inflammation and neuronal irritation. The electromyographic study showed that tonsillectomy affects the soft palate and pharyngeal muscles activity and result in abnormal contraction.[11] Posttonsillectomy pain can occur due to different causes and even the pain can ensue simply from the positioning of the patient during tonsillectomy.[12] The Boyle-Davis mouth gag itself can produce pressure and venous congestion of the tongue, resulting in postoperative discomfort and swelling as well as temporomandibular joint strain. Tonsillectomy creates large areas of the exposed muscle in the oropharynx, leading to considerable pain from the spasm of the muscle and irritation of the nerve endings.[13] Excessive dissections and the use of cautery hemostasis during tonsillectomy may produce a greater incidence of inflammation and postoperative pain.[14] Patients with posttonsillectomies often complain of ear pain, presumably referred otalgia which occurs through a glossopharyngeal nerve. Removal of the tonsil triggers the inflammatory process which facilitates the healing process at the tonsillar fossa region but also leaves an open wound that exposes the nerve fibers and damaged muscle fibers.[15] This makes postoperative wounds vulnerable to mechanical injury during eating or swallowing. Posttonsillectomy wound shows evidence of inflammation and infection by producing a thick fibrin layer which increases in size by the first 3–4 days postoperatively.[16] This fibrin layer begins to shed at approximately 7 days and then allows the bed to remucosalize by the end of the 2nd week.[17] By this healing process, postoperative pain can be manifested in a biphasic pattern with a peak at around 3–7 days but may persist for 2–3 weeks following surgery.[17] In the case of children, poorly handled posttonsillectomy discomfort can cause anxiety for both patients and parents. It also causes dehydration in the patient due to a lack of liquids and food intake. The treatment of posttonsillectomy pain is always the priority in patients, particularly in children.

Nonpharmacological treatment

Cold diet

One study reported that rinsing of the tonsillar fossae by physiological saline at 4°C for 10 min at the end of the surgery reduces the immediate posttonsillectomy pain.[18] Similarly, drinking iced water help to reduce the pain immediately after surgery.[19] Patients should be advised to drink plenty of fluids after tonsillectomy. Staying hydrated can reduce posttonsillectomy pain.

Mouthwashes

After tonsillectomy, various therapies are required to reduce morbidity while reducing adverse effects and topical medicines appear to be an ideal and safe option. Mouthwashes and topical sprays can help relieve discomfort while also reducing the risk of bleeding in the days following a tonsillectomy.[20] There are several mouth rinses, sprays, and mouthwashes are available for reducing posttonsillectomy pain. Benzydamine hydrochloride solutions help decrease pain following tonsillectomy.[21] Hydrogen peroxide mouth gargle is helpful to maintain anti-sepsis, prevent bleeding from the tonsillar fossa region and reduce posttonsillectomy pain.[22] Lidocaine gargle helps to decrease pain following tonsillectomy because of its anesthetic properties.[23]

Honey

Oral administration of honey following tonsillectomy in children may decrease the requirement of analgesics for relieving postoperative pain.[24] Honey often speeds up the healing process in the wound by stimulating the production of inflammatory cytokines from monocytes and keratinocytes.[25] Honey stimulates monocytes to secrete cytokines like interleukin (IL) of IL-1B and IL-6 and tumor necrosis factor-alpha. These mediators play a vital role in healing and tissue repair.[26] According to one study, 5 days of regular honey ingestion reduced pain scores and painkiller intake for the first 3 days after tonsillectomy.[27] Nitric oxide and prostaglandins play a vital role in the inflammation, microbial killing, and healing process of the wound. Honey is found to reduce prostaglandin levels and increase nitric oxide end products. These properties of the honey help to explain its therapeutic properties as an antibacterial agent or wound healing.[28] The side effects of honey are almost negligible and so suggested for routine use along with analgesics in the posttonsillectomy period. Honey can be used if the child is more than 1 year old and not allergic to honey. The child can take it as one teaspoonful three times/day.[28]

Chewing gum

Patients are traditionally advised for eating early and frequently during the initial time of the posttonsillectomy period for reducing the severity of the pain and facilitating the early resumption of a normal diet.[29] Activation of mastication and promotion of salivation along with deglutition in the postoperative period help to get early recovery of the posttonsillectomy patients. One study showed the analgesic effects of chewing gum in the posttonsillectomy period.[30] However, one report showed that chewing gum results in delayed normalization of feeding and an increased period of posttonsillectomy pain.[4] Chewing gum speeds comfortable swallowing by reducing the spasm of the pharyngeal muscles after surgery. Hence, chewing gum should not be considered a treatment option. However, regular use of chew gum fails to mimic the physiological process of swallowing as mastication of gum will enhance the saliva production in the absence of passage of food on deglutition and frequent swallowing promote aerophagia and so suppress the appetite.

Voice/oral exercises

Posttonsillectomy pain occurs due to spasm of the pharyngeal muscles (constant pain) or contraction (during swallowing) along with inflammation and neuronal irritation.[31] Sometimes, children use nasal voice after tonsillectomy for avoiding posttonsillectomy pain. This pain is caused by limiting movement of the muscles near the tonsillar bed and additional escape of air through the nose. The voluntary contraction and stretching of the soft palate muscles by speaking or speech therapy may reduce the inflammation by increasing the blood supply of the wound. Hence, speech therapy might relieve the posttonsillectomy pain derived from the inflammation and muscle spasm. Speech therapists often suggest blowing a scarf off over the face, whistles, advised to tell ahh, and hold it for long period for reducing posttonsillectomy pain. The oral or voice exercises include blowing bubbles, blow out candles or blow cotton balls across the tables through a straw. In the posttonsillectomy period, voice exercises help to mobilize the soft palate muscles (closed phonemes), with 25 phonemes repeated 10 times/day, significantly minimizes the posttonsillectomy pain in pediatric patients.[32] Speech therapy may be helpful to strengthen the muscles of the soft palate and alleviate posttonsillectomy pain. This speech therapy may be useful as a complementary with analgesics.[30]

Omega 3, polyamines

Omega-3 long-chain polyunsaturated fatty acids can have an impact on wound healing in humans and animals.[33] Omega-3 fatty acids from fish oil can stop wound infections and improve wound healing, but after few days may reduce the deposition of collagen, possibly preventing extensive scarring at the wound. Omega-3 fatty acids also help to reduce neuropathic pain.[33] Dietary omega 3, omega-3/omega-6 ratio polyamines point to decrease hyperalgesia in chronic pain and postoperative pain in general surgery by taking a low-polyamine diet (orange-based).[34],[35]

Homeopathy

Few studies have shown the effectiveness of specific homeopathic remedies for throat pain due to many causes. Aconitum is helpful for throat pain or sore throat with high fever which works best if given immediately after symptoms begin. One study reported that intake of Arnica montana for 1 week following tonsillectomy reduces postoperative pain.[36]

Acupuncture

Acupuncture is an effective complement to the NSAID in the management of posttonsillectomy pain. Patients particularly those who have drug intolerance, allergies, or decreased response to commonly used drugs may benefit from acupuncture. Acupuncture has been studied for posttonsillectomy nausea and vomiting, but the effectiveness in terms of posttonsillectomy pain has yet to be determined.[37] Acupuncture can also be beneficial for pediatric patients. In one study, 11.8% of patients experienced moderate side effects, with few serious problems due to poor execution.[37] One study demonstrated that the application of acupuncture is an effective treatment method in addition to conventional analgesics for managing posttonsillectomy pain in the pediatric age group.[38] Sertel et al. showed that acupuncture had significant effects on the treatment of posttonsillectomy pain while the control group did not reduce pain significantly.[39]

Ice collar

An ice collar can be useful to reduce posttonsillectomy pain. The ice collar can be made by placing the ice cubes and water in a large Zip-loc bag and wrapping it in a cloth/towel. Then gently keep this ice pack in front of the neck.[40]

Behavioral therapy

Concentration on pain will amplify it, so the pain is perceived as more intense. As a result, using music, video games, and social engagement to distract yourself from the pain will make it less acute. Distraction was found to improve the severity of persistent stomach discomfort in children in one research.[41] The findings were applied through entertainment in the posttonsillectomy period to reduce the pain.[42] One study demonstrated that training/coaching of the children for pain management by deep breathing, visual projection, relaxation, music through audiovisual supports and book decreased the pain in posttonsillectomy period and anxiety in hospital; however, that effect decreased significantly once discharged from hospital.[43] Although hypnosis is not much studied in tonsillectomy, there are few assessments in postoperative in general. According to one review, hypnosis in children after a general surgical procedure was found to be useful in terms of anxiety and postoperative pain duration.[44] If such hypnosis therapy is given to children, this must be informed to parents and the concerned staff also need appropriate training.

Cryoanalgesia

The reduction of pain following the posttonsillectomy period is an important challenge for a clinician, not because of patient comfort, but also for improvement of oral intake which decreases the risk of dehydration, infection, and posttonsillectomy hemorrhage.[45] Cryoanalgesia is a new approach for reducing pain after a tonsillectomy. Patients who undergo cryoanalgesia return to work or school, on average 4 days earlier than those who had not undergone cryoanalgesia.[46] Cryoanalgesia requires the insertion of two needles superficially into the tonsillar fossa. Each cooling application stays for 60 s with a probe temperature of −56°C which provides tissue temperature of −20°C to −32°C.[46] In this technique, cooling of the tissue reduces the inflammation, probably via vasoconstriction and subsequent decreasing edema and pain-producing mediators. Nerve fibers that are cooled lose their conduction at a rate proportionate to the degree of cooling.[47]

Future perspective/research

There is a significant gap in the literature related to the management of posttonsillectomy pain and appropriate nonpharmaceutical agents. Protocol for pain reporting, deciding factors for patient-relevant outcomes as well as evidence-based guidelines for successful treatment of the posttonsillectomy pain with nonpharmaceutical agents are still not addressed. It requires improved follow-up and longer period monitoring for a successful outcome. Currently, there is a great heterogenicity related to different nonpharmaceutical agents for the management of posttonsillectomy pain. Genetic links to the pain perception and response to nonpharmaceutical agents are still being investigated and can help personalize and patient's outcome. Finally, successful management of posttonsillectomy pain requires a balance between pain control and side effects of nonpharmaceutical agents which is often a challenge for clinicians or otolaryngologists.


  Conclusion Top


Tonsillectomy is a typical daycare surgical operation that comes with a lot of pain afterward. Despite several treatment options such as analgesics are available for controlling postoperative pain there are still patients who experience marked posttonsillectomy pain. Currently, there are certain nonpharmacological therapies have been available for effective management of posttonsillectomy pain. Nonpharmacological therapies are often associated with no adverse effects and more patient compliances by reducing posttonsillectomy pain. Lidocaine oral gargle helps to reduce the pain following tonsillectomy because of its anesthetic properties. Hydrogen peroxide gargling is also helpful to maintain anti-sepsis, prevent bleeding from the tonsillar fossa region and reduce posttonsillectomy pain. A cold diet is often useful to control posttonsillectomy pain in the first 24 h.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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