Clinical Study

Ear, Nose & Throat Journal

2019, Vol. 98(6) 356–361
Pain Management After Surgical ª The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
Tonsillectomy: Is There a Favorable DOI: 10.1177/0145561319846065
journals.sagepub.com/home/ear
Analgesic?

Ana Jotić, MD, PhD1,2, Katarina Savić Vujović, MD, PhD3,

Jovica Milovanović, MD, PhD1,2,4,5, Aleksandar Vujović, MD6, Zorana Radin, MD7,
Nataša Milić, MD, PhD8,9, Sonja Vučković, MD, PhD3,
Branislava Medić, MD, PhD3, and Milica Prostran, MD, PhD3

Abstract
The aim of this study was to examine how ibuprofen and paracetamol prevent pain after cold-steel extracapsular tonsillectomy in
children. Also, we examined the relation between age, gender, nausea, postoperative bleeding, antibiotic use, type of diet, and
postoperative pain intensity and the type of administered analgesic. A prospective study was conducted on 147 children (95 males
and 52 females, aged 7-17 years) who underwent tonsillectomy in the Clinical-Hospital Center ‘‘Dragiša Mišović’’ from January
1 to June 30, 2016. The degree of pain was measured using a visual analog scale (VAS). We did not observe any significant dif-
ferences in postoperative nausea, hospitalization rate postoperative bleeding, and antibiotic use between the paracetamol and
ibuprofen groups. A test of within-patient effects showed that VAS scores changed significantly during the postoperative follow-up
period (P ¼ .00), but there were no significant differences between the groups (P ¼ .778). After 12 hours, 29.3% of the patients on
paracetamol and 21.8% on ibuprofen were transferred to a soft diet; after 24 hours, 84.8% of the paracetamol group and 85.5% of
the ibuprofen group were on a soft diet (w2 test, P < .05). There was a statistically significant correlation between VAS scores
measured 4 hours after the surgery and the time of transference to the soft diet (Spearman r test, P < .001). The transfer to soft
and normal diets was not significantly different between the 2 groups as assessed by the VAS scores (Pearson w2 test,
P ¼ .565).There is still no consensus on the most effective postoperative pain-control regiment after tonsillectomy. This study
showed that satisfactory pain management was achieved equally with both paracetamol and ibuprofen.

Keywords
tonsillectomy, pain, analgesics, paracetamol, ibuprofen

Introduction
Tonsillectomy is one of the most frequent surgical procedures
in the world. Although the first intervention for tonsil removal
was described by Celsus in the first-century AD, it was not until
1757 that Rheims described the first surgical technique of ton-
sillectomy.1 Today, the most commonly used procedure is cold
dissection extracapsular tonsillectomy.2 Other techniques using
bipolar electrocautery, laser, harmonic scalpel, and bipolar
radiofrequency have been introduced in the attempt to lower
the intensity of pain and postoperative bleeding.3
The main postoperative concerns include pain, dehydration,
and postoperative bleeding. Use of analgesics postoperatively is
highly recommended. Also, postoperative analgesic consumption
and nausea can be significantly reduced with perioperative and
postoperative administration of high doses of steroids (dexa-
methasone or prednisolone), as recommended in the guidelines.4,5
There are several reasons why the first 7 days after tonsil-
lectomy could be problematic. Dehydration and poor food
1
Clinic for Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of
Serbia, Belgrade, Serbia
2
Department of Otorhinolaryngology and Maxillofacial Surgery, Faculty of
Medicine, University of Belgrade, Belgrade, Serbia
3
Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty
of Medicine, University of Belgrade, Belgrade, Serbia
4
Faculty of Medicine, University of Belgrade, Belgrade, Serbia
5
Clinic of Maxillofacial Surgery, Sechenov University, Moscow, Russia
6
Hospital for ENT, KBC DragišaMišović, Belgrade, Serbia
7
General hospital ‘‘Djord̄e Jovanović’’, Zrenjanin, Serbia
8
Division of Nephrology & Hypertension, Mayo Clinic, Rochester, MN, USA
9
Department of Biostatistics, Medical Faculty, University of Belgrade, Belgrade,
Serbia
Received: January 24, 2019; revised: April 1, 2019; accepted: April 3, 2019
Corresponding Author:
Katarina Savić Vujović, MD, PhD, Department of Pharmacology, Clinical
Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade,
Dr Subotića-starijeg 1, PO Box 38, 11129 Belgrade, Serbia.
Email: katarinasavicvujovic@gmail.com
Jotić et al
intake are closely associated with increased pain after tonsil-
lectomies.6 Noncompliant caregivers and not administrating
analgesics to children postoperatively could be another signif-
icant contributing factor to poor control of postoperative pain.
Also, it is under debate whether the administration of analge-
sics according to a fixed schedule is more efficient than dosing
the medication as needed (PRN), since studies have indicated
that children still complain of moderate pain intensity in both
instances.7,8 It was suggested that pain perception depends on
the age of the child. Some studies reported that children
younger than 12 years complained of less pain after tonsillect-
omy than teenagers and adults.9
Standard analgesics used in postoperative child care in
Serbia include nonsteroidal anti-inflammatory drugs
(NSAIDs; ibuprofen or diclofenac) and paracetamol (aceta-
minophen). Opioids are not used for treating postoperative
tonsillectomy pain.
The aim of this study was to examine how ibuprofen and
paracetamol prevent pain after cold-steel extracapsular tonsil-
lectomy. Also, we wanted to establish if age, gender, post-
operative diet, occurrence of nausea, postoperative bleeding,
repeated hospitalization, and antibiotic use were related to
postoperative pain intensity and the type of administered
analgesic.
Materials and Methods
This prospective study was conducted on 147 children (95
males and 52 females, aged 7-17 years) who underwent tonsil-
lectomies in the Clinical-Hospital Center ‘‘Dragiša Mišović’’
from January 1 to June 30, 2016. The study and its duration
were approved by the Institutional Ethics Board (decision num-
ber 1277/15). Indication for tonsillectomy was set according to
a detailed history of the disease, documented episodes of recur-
rent tonsillitis, clinical examination, and laboratory tests. Chil-
dren suffering from obstructive-sleep apnea weren’t included
in the study. All patients underwent cold-steel extracapsular
tonsillectomy under general endotracheal anesthesia. During
surgery, anesthesia was delivered via inhalation of O2/nitrous
oxide and sevoflurane (1.5-3 vol%), intravenous propofol (2.5-
3 mg/kg), fentanyl (2-5 mcg/kg), rocuronium (0.6-0.8 mg/kg),
or cis-atracurium (0.15 mg/kg). Antiemetic prophylaxis was
conducted with dexamethasone (150 mg/kg).
Patients were followed until the first postoperative control,
7 days after the surgery. Patients were randomized by simple
randomization into 2 groups, first group of 92 patients treated
with paracetamol and second of 55 patients treated with ibu-
profen for postoperative pain management. There are no dif-
ferences between the groups according to age and gender.
Analgesics were administered according to a fixed schedule
given in the therapy chart: paracetamol: 10 to 15 mg/kg/dose
every 6 hours (maximum 100 mg/kg/d or 4 g/d if >50 kg), or
ibuprofen: 10 mg/kg/dose every 6 hours (maximum 40 mg/kg/d
or 2.4 g/d). The degree of pain was measured using a visual
analog scale (VAS; 0-100 m). The VAS was arranged as a 100-
mm horizontal line with 2 end points (no pain and worst pain
357
possible). The child was asked by a doctor to place a mark on
the line at a point which they feel that represents the intensity of
their pain. The VAS is scored by measuring from no pain to the
point selected on the scale. Information and explanation on
how to use VAS scale was provided to a child upon hospital
admittance. Information about the type of diet (clear fluid, soft
diet, or normal diet) was recorded, based on the information
provided by the parents or guardians. In cases of postoperative
fever (above 38 C) and high white cell blood counts (above 12
 109/L), ceftriaxone was given for up to 3 days (in children
<50 kg, 50-80 mg/kg once a day up to 2 g a day; in children >50
kg, 2 g once a day), with a switch to therapy with oral anti-
biotics, cefixime or cefpodoxime, for up to 7 days. Data for
postoperative nausea, bleeding, repeated hospitalization, and
antibiotic use were recorded during the follow-up period. Mea-
surements were made 4 hours, 12 hours, 24 hours, and 7 days
postoperatively.
SPSS v20 (SPSS Inc, Chicago, Illinois) was used for statis-
tical analysis. Sample size was calculated based on a contin-
uous response variable, that is, mean VAS pain scale from
ibuprofen and paracetamol groups with 1:2 allocation ratio. For
expected moderate size effect (Cohen d ¼ 0.45), calculated
sample size was 47 and 93 patients per ibuprofen and parace-
tamol group, respectively, to be able to reject the null hypoth-
esis that the population means of the groups are equal with
probability (power) 0.8. The type I error probability associated
with testing this null hypothesis is .05.The total number of
patients recruited for the study was then estimated to be 140.
Descriptive statistics were calculated for demographic charac-
teristics, risk factors, and other followed parameters and are
presented as means (standard deviations [SD]), medians with
interquartile ranges, or absolute and relative frequencies. t test,
w2 test, and analysis of variance for repeated measures were
used to establish statistical differences between parameters.
Statistical significance was considered at P <.05.
Results
The study included 147 patients, of which 95 (64.6%) were
males and 52 (35.4%) were females. Patients were randomized
into 2 groups: first, 92 patients treated with paracetamol and
second, 55 patients treated with ibuprofen for postoperative
pain management. Before surgery, most of the patients were
without any preexisting condition or disease and were not using
medication (94%). Nine patients (6%) had asthma and were on
fenoterol–ipratropium bromide. All patients were without any
respiratory infections or antibiotic therapy at least 3 weeks
before the surgery.
Patients were of the age 7 to 17 years, with a mean age of
9.54 years. Patients who were treated with paracetamol post-
operatively had a mean age of 9.75 (SD 2.744), and patients
treated with ibuprofen had a mean age of 9.2 (SD 2.656). There
were no significant differences in age between the 2 groups
(t test, P ¼ .236). Data about gender distribution, postoperative
nausea, bleeding, hospitalization, and antibiotic use are pre-
sented in Table 1. The gender distribution was equal between
358 Ear, Nose & Throat Journal 98(6)

Table 1. Gender Distribution, Postoperative Nausea, Bleeding,

Hospitalization, and Antibiotic Use for Patients Treated With
Paracetamol and Ibuprofene.

Analgesic

Paracetamol Ibuprofen

N % N % P Value

Gender
Male 61 66.3 34 61.8 .582
Female 31 33.7 21 38.2
Nausea
No 85 92.4 51 92.7 .940
Yes 7 7.6 4 7.3
Bleeding
No 92 100.0 55 100.0 –
Yes 0 0.0 0 0.0
Hospitalization
No 90 97.8 51 92.7 .131
Yes 2 2.2 4 7.3
Antibiotic
No 77 83.7 42 76.4 .273
Yes 15 16.3 13 23.6

Figure 1. Postoperative VAS scores for patients treated with

Table 2. Postoperative VAS Scores for Patients Treated With paracetamol.
Paracetamol and Ibuprofen.

Mean SD Table 3. Postoperative Diet for Patients Treated With Paracetamol

and Ibuprofen.
VAS 4 hours
Paracetamol 5.84 0.684 Analgesic
Ibuprofen 5.93 0.766
VAS 12 hours Paracetamol Ibuprofen
Paracetamol 5.3 0.722
N % N % P Value
Ibuprofen 5.33 0.924
VAS 24 hours Diet 4 hours
Paracetamol 4.78 0.887 Clear fluid 92 100.0 55 100.0 –
Ibuprofen 4.78 0.875 Diet 12 hours
VAS 7 days Clear fluid 65 70.7 43 78.2 .317
Paracetamol 1.42 1.439 Soft diet 27 29.3 12 21.8
Ibuprofen 1.58 1.41 Diet 24 hours
Abbreviations: SD, standard deviation; VAS, visual analog scale.
Clear fluid 21 17.9 6 13.0 .912
Soft diet 78 84.8 47 85.5
Diet 7 days
groups. There were no significant differences in postoperative Clear fluid 1 1.1 0 0.0 .584
Soft diet 63 68.5 41 74.5
nausea, hospitalization rate, and antibiotic use between the
Normal diet 28 30.4 14 25.5
groups treated with paracetamol and ibuprofen. No postopera-
tive bleeding was recorded during the 7-day follow-up period.
The VAS scores measured postoperatively are shown in on soft diet (w2 test, P ¼ .912). Seven days after the surgery,
Table 2 and Figure 1. The test of within-patient effects showed 68.5% of the patients in the paracetamol group were on the
that VAS scores changed significantly during the postoperative soft diet and 30.4% were on the normal diet. In the ibupro-
follow-up period (P ¼ .00), but there were no significant dif- fen group, 74.5% were on the soft diet and 25.5% were on
ferences between groups (P ¼ .778). the normal diet (w2 test, P ¼ .584). There was no statistical
All patients had a clear fluid meal 4 hours after surgery difference between the groups transferred to either the soft
(Table 3). After 12 hours, 29.3% of the patients who or normal diets (w2, P ¼ .565).
received paracetamol and 21.8% of the patients who We examined variations of the VAS score depending on
received ibuprofen were transferred to a soft diet (w2 test, gender, age, and type of diet during the postoperative follow-
P ¼ .317). After 24 hours, 84.8% of the patients in the up period. The VAS scores did not significantly vary depend-
paracetamol group and 85.5% in the ibuprofen group were ing on age (tests of between-patient effects, P ¼ .675) and
Jotić et al
gender (tests of between-patient effects, P ¼ .899), and they
were not statistically significant. Transfer to soft and normal
diet was not significantly different between the 2 groups
depending on VAS scores (w2, P ¼ .565). However, there was
statistical significant correlation between VAS scores mea-
sured 4 hours after the surgery and the time of transfer to the
soft diet; if the VAS scores were lower, the transfer to soft diet
was quicker (Spearman r test, P < .001).
Discussion
Tonsillectomy is one of the most frequently performed sur-
geries in the pediatric population. Considering that it is per-
formed as a 1-day surgery, postoperative pain management is
one of the main concerns. It can affect postoperative liquid and
food intake, speed of recovery, and everyday activities in
children.
Reliability and validity of VAS, as a self-assessment mea-
sure, have been the widely explored and well established.10
Considering cognitive ability and age, it was confirmed that
VAS can be reliably and accurately used in children aged
7 years and older.11-13 The VAS scores have been shown to
be sensitive to changes in pain levels during postoperative
periods14 and following analgesic medications.15 The mini-
mum clinically significant difference in the VAS pain score
for children 8 to 15 years old was determined to be 10 mm
(95% confidence interval, 7-12 mm).16 Reliability of the VAS
for acute pain measurement was assessed at 90%, with the
repeatability coefficient in children aged 8 to 17 years that
varies from 6 to 12 mm on a 100-mm VAS.17-19 Children’s
VAS scores were shown to correlate significantly with parent
ratings of children’s pain and with medical personnel, as well
as the scores of other types of pain.13
Our study used VAS to evaluate the effects of paracetamol
and ibuprofen as 2 of the most commonly used analgesics in
pain management after cold dissection extracapsular tonsillect-
omy. In Serbia, opioids are not in use for postoperative tonsil-
lectomy pain management.
The analgesic effects of paracetamol are mainly through
central mechanisms, by inhibition of central COX systems,
stimulation of descending serotonergic pathways, and indirect
activation of cannabinoid receptors.20 Nonsteroidal anti-
inflammatory drugs also act by inhibiting COX, but there are
differences. Paracetamol has a weak anti-inflammatory effect,
few or no gastrointestinal side effects, and causes only a small
dose-dependent alteration in platelet function.21
Ibuprofen as NSAID has become a significant choice for
postoperative analgesia. Although it provides adequate pain
management, 22 its routine use remains controversial as
NSAIDs also potentially cause platelet dysfunction that can
lead to increased risk of postoperative bleeding.23 Studies
showed that a single dose of ibuprofen between 300 and 900
mg inhibits platelet aggregation 2 hours after administration.
Low doses of ibuprofen (200 mg 3 times daily) didn’t prolong
the bleeding time, but higher doses (up to 600 mg 3 times
daily) influenced on bleeding time prolongation after
359
administration.24 In this study, postoperative bleeding was not
noted in either patients who used acetaminophen or in those
who used ibuprofen for a follow-up period of 7 days. Due to
specific pharmacokinetic of ibuprofen, any adverse effects of
ibuprofen would be expected in that time frame. Secondary
bleeding occurs more than 24 hours after the surgery, often
between 5 and 10 days, and is usually caused by fibrin layer
detachment during healing.7 According to recent literature,
evidence confirming an increased risk of postoperative ton-
sillectomy bleeding associated with NSAID therapy is
lacking.25-28
The regime of analgesic administration is still discussed in
the literature. Medication according to a fixed schedule is
widely used, as it was in our study; however, this could still
be insufficient for pain management after tonsillectomy.
According to a few clinical trials, during pain management
with different analgesics as one medication (acetaminophen)
or a fixed combination (acetaminophen and codeine or rofe-
coxib and hydrocodone), a fixed schedule is more effective
than dosing medication PRN after tonsillectomy.7,29 A fixed
administration schedule is especially required to obtain para-
cetamol’s optimal analgesic effect. Its central activity depends
on transport across the blood–brain barrier through passive
diffusion, which is highly dependent on sufficiently high
plasma concentrations of paracetamol. After oral administra-
tion, paracetamol uptake occurs mainly in the small intestine,
so that plasma concentrations might be affected postopera-
tively because of impaired gastric emptying. It is known that
surgical intervention itself can decrease gastrointestinal moti-
lity and delay gastric emptying; however, opioid analgesics, the
fasting state, and supine positioning can all contribute to it.30,31
As a result of paracetamol absorption, after oral dosing, its
concentrations may not be as per published pharmacokinetic
data, so that its fixed administration can provide adequate
serum levels. Although some studies deemed paracetamol to
be a safe drug but not potent enough to provide efficient
analgesia after tonsillectomy, our results showed that parace-
tamol and ibuprofen have a very similar analgesic effect when
administered according to a fixed schedule.7,8
In the study, paracetamol was used for pain management
was used in 92 patients, and ibuprofen was used in 55 patients.
There are number of different available analgesics from
NSAID group, and there is no significant difference in their
efficacy. There are, however, significant individual variations
in the patients’ response to those analgesics.32 For developing
an appropriate postoperative pain management plan, an assess-
ment of past and current history of pain, including the use of,
response to, and preferences for certain analgesics, is needed.33
The choice of the right analgesic in this study was made by both
physician and patient (or in many of cases in this study, parent
or a guardian) on the balance between efficiency and risk and
previously used analgesics that were efficient in pain
management.
The children included in our study complained of moderate
pain during the first 12 hours after surgery, with VAS scores
below 6 in both groups, and below 5, 24 hours after the surgery.
360
Seven days after the surgery, the children complained of mild
pain, with VAS scores below 2 in both groups. No significant
differences were noted between the paracetamol and ibuprofen
groups, although the scores for the paracetamol group were
slightly lower at 4 hours, 12 hours, and 7 days after surgery.
We can say that postoperative tonsillectomy pain has its own
natural course. Many studies have indicated that children, irre-
spective of the dosing regimen and analgesic choice, complain
of moderate-to-severe pain, with VAS scores above 5 in the
first 7 days after tonsillectomy. After 7 days, the VAS scores
decreased significantly.31,34,35 We could consider ibuprofen
and paracetamol successful in achieving analgesia with VAS
scores below 6 after tonsillectomy.
In other studies, no significant association between chil-
dren’s age and sex and the intensity of postoperative pain was
observed, which was also observed in our study.36,37 Some
authors used other measures, such as returning to a normal diet,
refusing fluids, nausea, antibiotic use, and readmission to indir-
ectly quantify postoperative pain.38,39 In our study, children
with nausea who were readmitted to the hospital and treated
with antibiotics did not report significantly greater pain inten-
sity. Pain intensity significantly influenced the transfer of
patients from a liquid to a soft diet, but not from a soft to a
normal diet. A possible explanation lies in the pathophysiology
of the healing process after tonsillectomy.40 Edema and pain
are greatest immediately after surgery, probably as a result of
thermal effects and the expression of inflammatory mediators
that stimulate pharyngeal nociceptors. The VAS measurements
in this study were performed in the first 4, 12, and 24 hours
postoperatively to obtain result indicating moderate pain levels.
Using paracetamol or ibuprofen was crucial for pain manage-
ment and for early postoperative course in these children. Pain
gradually decreases over time, with an increase in pain mea-
sured on postoperative days 3 to 5, which corresponds to max-
imal wound inflammation. Due to our study design, patients
weren’t available for measures until first postoperative control
on postoperative day 7. A fibrin layer starts forming after the
surgery, followed by inflammation of the surrounding tissue.
From postoperative day 7, fibrin starts to shed and reepitheliza-
tion is usually finished by the end of 2 weeks. After the first
week, pain significantly decreases. In our study, 30.4% of the
children in the paracetamol group and 25.5% of those in the
ibuprofen group returned to a normal diet 7 days after surgery.
The study has few weaknesses. First, although analgesics
were administrated according to a fixed schedule, there are
no measures of compliance with the administration of analge-
sics in our patients. According to the literature, compliance of
the parents or guardians with the administration of analgesics
following tonsillectomy is problematic.7 Significant number of
children receive little or no medication, despite reporting mod-
erate to severe pain. Possible direction of future research of
analgesics effectiveness should involve medication administra-
tion logs and a measure of total administered medication.
Second, the results indicate that there aren’t significant dif-
ferences in the pain management between these 2 medications.
However, it should be emphasized that this isn’t same as
Ear, Nose & Throat Journal 98(6)
equivalence. Two medications used for pain management in
the study have different chemical structure, mechanism of
action, and dosing regime, but their effect on pain management
after tonsillectomy was without significant differences.
Although this study showed similar effects of paracetamol and
ibuprofen in pain management, a possible future direction in
post-tonsillectomy analgesia could be a multimodal approach.
There is evidence that simultaneous administration of parace-
tamol and ibuprofen in the pediatric population is superior to
monotherapy.41,42 According to Swedish guidelines, COX
inhibitors combined with paracetamol given regularly are often
sufficient for 5 to 8 days after tonsillectomy.43
In conclusion, there is still no consensus as to what is the
most effective postoperative pain-control regiment after tonsil-
lectomy. Also, the methods of pain measurement in studies are
very heterogeneous, especially for the pediatric population.
Postoperative analgesia needs to be effective and safe for chil-
dren. This study showed that satisfactory pain management was
achieved effectively with either paracetamol or ibuprofen with-
out unwanted complications.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by the Ministry of Education, Science and Technolo-
gical Development of the Republic of Serbia (Grant No. 175023).
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