ORIGINAL ARTICLE

Post-Tonsillectomy Pain and Bupivacaine, An Intra Individual

Design Study
Amer Sabih Hydri1 and Sher Muhammad Malik2

ABSTRACT
Objective: To compare whether an individual could appreciate the pain relief, if any, in either one of his/her tonsillar fossa
topically suffused with a local anaesthetic (bupivacaine).
Study Design: Randomized controlled trial.
Place and Duration of Study: Department of ENT/Head and Neck Surgery, Combined Military Hospital, Peshawar, from
January to June 2007.
Methodology: Forty-six patients of either gender, aged 10-42 years undergoing tonsillectomy for recurrent tonsillitis were
enrolled for this study. At the end of surgery, having secured haemostasis, one tonsillar fossa was randomly packed with
a gauze piece soaked in 3 ml of 0.5% bupivacaine for 5 minutes, while the other was not. Effects of postoperative analgesia
were assessed using visual analogue scale (VAS) up to 8 hours.
Results: Majority of the patients (85%, n=39) failed to experience an appreciable pain relief on the side of local anaesthetic
(bupivacaine) application (p=0.006).
Conclusion: Topical application of local anaesthetic (bupivacaine) confers no appreciable pain control in post-tonsillectomy
patients.

Key words: Tonsillectomy. Pain. Bupivacaine. Local anaesthetic. Pain assessment.

INTRODUCTION study was designed to assess whether an individual

Managing pain following tonsillectomy remains a
confounding challenge for the anaesthetist and the
treating surgeon as it impairs swallowing, which subse-
quently leads to infection, dehydration and secondary
haemorrhage. The pain which peaks around the fourth
or fifth postoperative day1 translates into delayed
recovery following surgery, prolonged hospital stay and
increased cost. Although adequate pain relief is
achieved with the use of narcotic analgesics yet their
use is fraught with adverse side effects. The patients
often have to strike a balance between optimal pain
control and the side effects of the analgesics used.2 This
obviates the need to achieve adequate pain control
using a local anaesthetic agent in conjunction with a
general anaesthetic.
Bupivacaine, a long-acting local anaesthetic,3 is the
most commonly reported local anaesthetic for paediatric
regional anaesthesia by virtue of its lower toxic threshold
compared with other local anaesthetics.4 Various studies
have argued the effectiveness of topical application of
0.5% bupivacaine in reducing postoperative pain with
conflicting results.5,6 Pain is a subjective feeling and the
thresholds vary from person to person, therefore, this
1 Department of ENT, Combined Military Hospital, Pano Aqil.
2 Department of ENT, Combined Military Hospital, Rawalpindi.
Correspondence: Dr. Amer Sabih Hydri, Department of ENT,
Combined Military Hospital, Pano Aqil.
E-mail: draamerhydri@gmail.com
Received July 28, 2009; accepted June 01, 2010.
could appreciate the pain relief, if any, in either one of
his/her tonsillar fossa topically suffused with local
anaesthetic (bupivacaine).
METHODOLOGY
Forty-six patients (92 tosillar fossae) of either gender,
American Society of Anaesthesiologists [ASA] physical
status I, aged 10-42 years, undergoing tonsillectomy for
recurrent tonsillitis were enrolled for this double blind
randomized controlled trial. Written informed consent
was taken from the parents/ patients and approval of a
protocol for this study was obtained from the local ethical
committee. The minimum cut off age was 10 years so
that the patient was sensible and articulate enough to
interpret the visual analogue scale (VAS). Exclusion
criteria included known allergy to bupivacaine, painful
conditions of the oropharynx like peritonsillitis and
peritonsillar abscess and conditions requiring surgery in
addition to tonsillectomy e.g. adenotonsillitis. Pre-
operatively, the patients/parents were instructed how to
express pain on a 100-mm scale (VAS). None of the
patient was pre-medicated on the night prior to surgery.
All the tonsillectomies were performed using a standar-
dized anaesthetic technique. Surgery was performed by
one of two senior otolaryngologists, using the same
dissection and snare technique. The bleeding was
controlled by bipolar diathermy.
At the end of surgery, having secured haemostasis, one
tonsillar fossa was randomly packed with a cotton swab
soaked in 3 ml of 0.5% bupivacaine for 5 minutes, while
the other was not.

538 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 538-541
Post-tonsillectomy pain and bupivacaine, an intra individual design study

Following surgery, and after recovery from the general The cumulative mean VAS scores over the first 8 post-
anaesthetic, pain intensity in the throat, difficulty while operative hours for odynophagia revealed greater
talking and odynophagia, were assessed by asking discomfort than the scores for pain at rest and pain while
patients to express their pain, on a VAS 100 mm scale speaking (p=0.095, Table IV).
(0 mm: no pain; 100 mm: maximum imaginable pain) and Table IV: Mean pain scores ± (SD) for first 8 hours postoperatively
recorded at 1, 2, 4 and 8 hours after surgery. Separate (n=46).
recordings for each tonsillar fossa in the same patient Pain at rest Odynophagia Pain while speaking
were made by the recovery room/ward nursing staff and Bupivacaine 6.85 ± 1.04 7.18 ± 1.55 6.85 ± 1.04
treated fossae (4-9) (4-9) (4-9)
an intern, blinded to the side treated. Ibuprofen orally
Untreated fossae 6.49 ± 0.74 7.09 ± 1.16 6.49 ± 0.74
was given as a routine analgesic 6 hours following
(5-8) (5-9) (5-8)
surgery. No additional analgesic supplement was given
till the next 6 hours. VAS scores for pain at rest, odynophagia and pain while
The statistical analysis was performed using “software speaking, increased gradually, albeit asymmetrically in
package for statistical analysis” (SPSS-10). Pain scores both tonsillar fossae over the first 6 postoperative hours
using VAS were documented as mean ± standard and receded after oral analgesia was routinely given 6
deviation (SD). Student’s paired t-test was used for hours postoperatively. Thus the 8 hourly score was lower
than the one hour score in all cases (p=0.132, Figure 1).
calculating p-values. A p-value of < 0.005 was considered
significant. Only few patients [15%, n=7] experienced an appreci-
able pain relief on the side of topical bupivacaine
RESULTS application (p=0.006). An interesting observation was
that majority of patients [85%, n=39] had significantly
The mean age was 18.2 years. Most of the patients more pain on the side where bupivacaine packing of the
(61% n= 28) in this study were in or around their teen tonsil fossa was done, compared to the side where no
ages, followed by those in their third decade (26% intervention took place (Figure 2). Age and gender had
n=12). Male: female ratio was 1:1 (Table I). no bearing on this observation.
At the first VAS pain recording, one hour post-
operatively; all patients were too distraught to discrimi-
nate any pain difference between their respective
tonsillar fossae or any change during swallowing.
The VAS scores of pain intensity at rest and during
speech were identical, however, VAS scores on the
untreated side were lower than the fossae treated locally
with bupivacaine (p=0.156, Table II).
The overall pain intensity increased on swallowing. The
increase in VAS scores compared to pain at rest was
statistically insignificant, (p=0.134) in the untreated
fossae and (p=0.106) in the treated fossae. The treated
side was more painful than the untreated side (Table III).
Table I: Age and gender distribution (n=46). Figure 1: The mean VAS scores showing a gradual rise in the first three
1-10 years 11-20 years 21-30 years 31-40 years 41-50 years readings and a sudden fall after oral analgesia at the 6th postoperative hour.
Male 1 15 6 1 1
Female 2 13 6 1 0

Table II: Mean scores ± (SD) for pain at rest and during speech
(n=46).
1 hour 2 hours 4 hours 8 hours
Bupivacaine 6.46 ± 0.50 7.17 ± 1.04 8.13 ± 1.02 5.67 ± 1.17
treated fossae (6-7) (5-8) (6-9) (4-7)
Untreated fossae 6.46 ± 0.50 6.48 ± 0.50 7.43 ± 0.50 5.61 ± 0.49
(6-7) (6-7) (7-8) (5-6)

Table III: Mean scores ± (SD) for odynophagia (n=46).

1 hour 2 hours 4 hours 8 hours
Bupivacaine 6.46 ± 0.50 7.86 ± 1.08 8.43 ± 0.74 5.97 ± 1.14
treated fossae (6-7) (6-9) (7-9) (4-7)
Untreated 6.46 ± 0.50 7.71 ± 0.54 8.39 ± 0.49 5.82 ± 0.64
Figure 2: Effect of local application of bupivacaine on the tonsillar fossae.
fossae (6-7) (7-9) (8-9) (5-7) Only 15% patients (n=7) experienced pain relief (p=0.006).

Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 538-541 539
Amer Sabih Hydri and Sher Muhammad Malik
DISCUSSION
In a bid to reduce post-tonsillectomy pain, variations in
surgical procedures, antibiotic injections and intra ope-
rative injection of corticosteroid have been attempted.7-9
Perioperative local anaesthetics are often used to
reduce the postoperative pain in tonsillectomy.10 There
are different ways of applying local anaesthetics, include:
pre-incisional peritonsillar infiltration, post-tonsillectomy
wound infiltration and post-tonsillectomy packing with
soaked gauze.
There is a multitude of studies both supporting and
refuting the effectiveness of bupivacaine. Ginstrom
claimed that intraoperative infiltration of bupivacaine/
epinephrine resulted in only a marginal effect on pain
and that too in the immediate postoperative period.11
Studies on bupivacaine infiltration in and around the
tonsillar fossae have yielded conflicting results varying
from no relief to appreciable pain control.12,13 Ventricular
tachycardia has been documented as an isolated compli-
cation of bupivacaine injection into the tonsillar bed.14
Wong concluded that postoperative bupivacaine injection
provides better pain relief than topical application.15 To
the contrary, Hung claimed that topical packing of
bupivacaine-suffused packs confers pain relief.16
Since the sides of intervention were pre-determined and
not randomly selected, an element of bias cannot be
ruled out in these studies.
The pain threshold varies from person to person, yet
almost all the published studies have compared the pain
perception among different groups of individuals and not
between the tonsillar fossae of an individual.
An exhaustive review of the Internet revealed only two
studies that have an intra-individual design similar to
ours. This is the only way to correctly document the
difference in pain perception after intervention in the
same individual.
The first study by Somdas found that 0.5 % bupivacaine
effectively relieves pain in children (patients aged 5-15),
which is in contrast to the findings of this study.17 The
two logical arguments are that considering the age
group, most of the patients are too young to localize the
side of maximum pain and appreciate its severity on a
VAS scale. Secondly the side of intervention was not
randomly selected and 0.5% bupivacaine solution was
infiltrated on the right tonsillar bed in all cases. This can
generate a biased result.
The only other intra-individual design study by Stelter
also claimed that post-tonsillectomy infiltration of the
wounds with bupivacaine is superior to pre-incisional
infiltration technique as well as post-tonsillectomy
packing of the wounds with a gauze swab.18 Pain
recordings were continued for 6 postoperative days.
The arguments against this study are that the younger
patients (age 3-45 years) are unable to respond accurately
540 Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (8): 538-541
to pain intensity and variation between the two tonsillar
fossae. Since the readings were objective, the result
would surely be unreliable at best. Secondly bupi-
vacaine is only effective locally up to 6-8 hours and
surely the concept of prolonged pain relief due to the
synergistic effect of a general/local anaesthetic is still
hypothetical.
An interesting finding of this study that bupivacaine
treated fossae were generally more painful is corro-
borated by a study by Warnock19 who also observed that
children who had a bupivacaine infiltration of the tonsil
fossa during surgery had significantly more pain in the
evening of surgery than children who did not.
Another study by Nordahl concludes that bupivacaine is
ineffective in relieving post-tonsillectomy pain in females
and older patients who reported more pain and used
more analgesics than males and younger patients.20
This corroborates the present findings, although in this
study the discomfort on the treated side was not
influenced by age or gender.
A review of Cochrane database encompassing thirty
trials till September 1998 reveals that since the trials
identified were of small size and several involved the
perioperative co-administration of intravenous opiates
which may have masked any beneficial effect of the local
anaesthetic, there is no evidence that the use of
perioperative local anaesthetic in patients undergoing
tonsillectomy improves postoperative pain control.21
This commensurate with the findings of this study.
CONCLUSION
Most of the patients i.e. 85% (n=39), failed to experience
an appreciable pain relief on the side of local anaes-
thetic (bupivacaine) application (p=0.006).
Large scale randomised controlled trials with an intra-
individual design are needed to resolve the enigmatic
role of topical bupivacaine in tonsillectomy.
Acknowledgement: The authors would like to thank Dr.
Jehangir Ahmed Afridi, Senior Intern, ENT Department,
Combined Military Hospital, Peshawar for his help in
collecting and compiling the VAS score data.
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