European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 239–241

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SFORL guidelines

Non-pharmacological treatment of post-tonsillectomy pain

P. Fayoux a,∗ , C. Wood b
a
Service d’ORL et chirurgie cervico-faciale pédiatrique, hôpital Jeanne-de-Flandre, CHRU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
b
Service de rhumatologie, centre de prise en charge de la douleur chronique, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France

a r t i c l e i n f o a b s t r a c t

Keywords: Tonsillectomy is a very frequent procedure, particularly subject to postoperative pain that is considered
Tonsillectomy long lasting and intense. Regulatory changes in the analgesic armamentarium, especially in children,
Pain are making the management of post-tonsillectomy pain more difficult. The present article provides an
Non-medical treatment
update on non-medical treatments that can be associated to classical analgesia.
Behavioral therapy
Materials and methods: A literature review of all studies of non-medical management in tonsillectomy
Local care
Acupuncture and postoperative analgesia, without restrictions of date, was performed on the Pubmed and Embase
databases.
Results: The treatment modalities described in the 24 selected studies could be categorized as behavioral,
local, acupuncture and general.
Conclusion: Although most studies reported benefit in terms of post-tonsillectomy pain, the small number
of studies per category precluded recommendations for current practice. It nevertheless seems useful
to consider and assess these techniques, to determine whether they have a role to play in the post-
tonsillectomy analgesic armamentarium.
© 2014 Published by Elsevier Masson SAS.

1. Introduction 2. Materials and methods

Tonsillectomy is a very frequent procedure, particularly in chil-
dren. Pain is an integral feature of post-tonsillectomy course, and
is usually considered intense and lasting 7–10 days [1–4].
The recent guidelines of the French health products safety
agency (Agence nationale de sécurité du médicament), dated April
12, 2013, restricted the market authorization for codeine to over
12 years old in case of failure of paracetamol and non-steroidal anti-
inflammatory drugs and contraindicated its use in tonsillectomy
and adenoidectomy [5]. The therapeutic armamentarium available
for post-tonsillectomy pain management has thus been reduced,
notably in children.
Several solutions may be considered to improve postoperative
analgesia: other analgesic molecules, surgical techniques induc-
ing less pain, and complementary analgesic techniques. A large
number of complementary analgesic techniques are in fact imple-
mented by patients, but few have been studied in evidence-based
medicine. The present study reviewed the literature to assess
complementary analgesic techniques for post-tonsillectomy pain
management.
∗ Corresponding author.
E-mail address: pierre.fayoux@chru-lille.fr (P. Fayoux).
A literature review using the Pubmed and Embase databases
reviewed studies of non-pharmacological treatments, behavioral
and assimilated techniques, speech therapy, acupuncture and local
oropharyngeal treatments in post-tonsillectomy or other postop-
erative pain management (without restriction as to organ). Only
prospective studies, methodologically correct retrospective stud-
ies, cohort studies and literature review were selected for analysis.
3. Results
On the above criteria, 24 publications were selected. Techniques
were categorized by concept, to determine the strategies described
for post-tonsillectomy pain management.
3.1. Behavioral and assimilated therapies
Concentrating on pain has the effect of amplifying it, so that it
is perceived as more intense. Conversely, distraction (music, video
games, interaction) may make the pain be perceived as less intense.
Walker et al. showed how distraction reduced the intensity of
chronic abdominal pain experienced by children [6] (level of evi-
dence 1). Conversely, the more empathetic the parents were with
respect to the pain, the more intense it was experienced as being.

http://dx.doi.org/10.1016/j.anorl.2014.07.002
1879-7296/© 2014 Published by Elsevier Masson SAS.
240 P. Fayoux, C. Wood / European Annals of Otorhinolaryngology, Head and Neck diseases 131 (2014) 239–241
The same findings applied to the use of entertainment in post-
tonsillectomy care [7] (level of evidence 4).
Huth et al. demonstrated that coaching children in pain manage-
ment (deep breathing, visual projection, relaxation, music) using
audiovisual supports and books reduced post-tonsillectomy pain
and anxiety in hospital, but that the effect ceased to be significant
after discharge at home [8] (level of evidence 2).
Hypnosis has not been specifically studied in tonsillectomy, but
there have been various assessments in postoperative pain more
generally. A literature review of peri-operative hypnosis in pedi-
atric general surgery found benefit in terms of anxiety and duration
of postoperative pain [9] (level of evidence 2). If such techniques are
to be used, the parents need to be given appropriate information
and staff need appropriate training [10] (level of evidence 2).
3.2. Local treatments
3.2.1. Cold
Horii et al. [11] (level of evidence 3) reported that rinsing the
tonsillar fossae with physiological saline at 4 ◦ C for 10 minutes at
end of surgery significantly reduced immediate postoperative pain.
Likewise, Sylvester et al. [12] (level of evidence 1) reported that
drinking iced water immediately after surgery reduced pain scores
between 15 minutes and 1 hour postoperatively; there was, how-
ever, no residual benefit by the 4th hour.
3.2.2. Mouthrinses, sprays and mouthwashes
Fedorowicz et al.’s 2013 review [13] covered all published stud-
ies of mouthrinses, sprays and mouthwashes in post-tonsillectomy
pain. Five of the 7 selected studies used benzydamide hydrochlo-
ride solutions [14–18], 1 hydrogen peroxide [19] and 1 lidocaine
[20] (level of evidence 1): only the last study reported benefit
in terms of pain, and only for the first 3 postoperative days. The
methodological defects of these studies, however, precluded any
of the treatments being formally recommended.
3.2.3. Honey
Boroumand et al. showed that 5 days’ daily consumption of
honey significantly reduced pain scores and analgesic intake for
the first 3 days following tonsillectomy [21] (level of evidence 1).
3.2.4. Chewing gum
Schiff, in 1982, reported analgesic effects of chewing gum post-
operatively [22] (level of evidence 4). Hanif and Frosh, in contrast,
reported delayed normalization of feeding and increased duration
of post-tonsillectomy pain [23] (level of evidence 1). Chewing gum
should therefore not be used as a treatment.
3.2.5. Speech therapy
Postoperative voice exercises, mobilizing the soft palate muscles
(closed phonemes), with 25 phonemes repeated 10 times a day for
10 days, significantly reduced post-tonsillectomy pain in children
[24] (level of evidence 2). This was, however, a Turkish study, and
the phoneme list is not directly transposable into French – although
an equivalent list could easily be put together.
3.3. Acupuncture and derived techniques
The use of acupuncture in tonsillectomy has mainly been stud-
ied in terms of postoperative nausea and vomiting. Efficacy in terms
of pain has been little assessed.
It is possible to use acupuncture in pediatrics. Adam et al.’s liter-
ature review [25] (level of evidence 2) found moderate side effects
in 11.8% of patients overall, and some severe complications due to
poor implementation.
Stimulation of point P6, by pressure (acupressure), puncture
(acupuncture) or electrically (transcutaneous electrical neurostim-
ulation: TENS), reduced postoperative nausea, but impact on
postoperative pain remains controversial [26–29] (level of evidence
2).
Acar et al. reported application of a capsaicin patch to point HT7
in 2 to 10 years old [30] (level of evidence 2). There was no reduction
in pain score, but reduced agitation after tonsillectomy.
There have been no studies of auriculotherapy in tonsillec-
tomy. One study reported reduced preoperative anxiety in general
surgery [31] (level of evidence 1).
3.4. Other general-route treatments
3.4.1. Homeopathy
Robertson et al., in 2007, reported reduced postoperative pain
after intake of Arnica montana 30ch for the first 7 days following
tonsillectomy [32] (level of evidence 1).
3.4.2. Omega 3, polyamines
There have been no studies in the context of tonsillectomy.
Data on the effects of dietary omega 3, omega-3/omega-6 ratio
and polyamines point to reduced hyperalgesia in chronic pain and
in postoperative pain in general surgery with low-polyamine diet
(orange-based) [33–35] (level of evidence 1).
4. Conclusion
The present literature review found that complementary
techniques exist which could be used in the management of post-
tonsillectomy pain. Most of the studies were methodologically
rigorous, but the small number of reports per technique precludes
formulating recommendations. In the present context of restric-
tion of the analgesic armamentarium, it would be worth examining
some of these techniques, in view of the relative lack of side effects.
Well-conducted prospective studies could confirm or invalidate the
data on complementary techniques presently found in the litera-
ture.
Acknowledgements
French ENT and Head and Neck Surgery Society (SFORL) work
group: Dr Sonia Ayari Khalfallah, Dr Alain Brunaud, Pr Isabelle
Constant, Dr Véronique Deramoudt, Pr Pierre Fayoux, Dr Cécile
Mareau, Pr Rémi Marianowski, Dr Justin Michel, Pr Michel Mondain,
Pr Richard Nicollas, Dr Arnaud Paganelli, Dr Soizick Pondaven, Pr
Philippe Schultz, Pr Jean Marc Treluyer, Dr Chantal Wood.
Editorial group: Dr Daniel Annequin, Dr Eric Baubillier, Dr Cécile
Bedfert, Dr Anita Chatellier-Miras, Pr Claude Ecoffey, Dr Céline
Forman-Glard, Dr Gildas Gueret, Dr Florentia Kaguelidou, Pr Bruno
Laviolle, Dr Véronique Lesage, Dr Catherine Nowak, Pr Gilles
Orliaguet, Dr Céline Richard, Dr Christian Sadek, Dr Barbara Tour-
niaire, Pr Francis Veyckemans.
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