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DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.2
bed and GNB) in relieving early postoperative pain after directed behind the posterior tonsillar pillar as laterally
tonsillectomy. In addition we also aimed to evaluate as possible and inserted through pharyngeal wall about
the success of GNB by examining gag reflex and find 0.5 1 cm in depth. After careful aspiration 1.5 ml of
correlation between obtunded gag reflex and post- bupivacaine solution was injected slowly. The technique
operative pain relief. was repeated on other side. The patients of group PT
METHOD received 3 ml of bupivacaine solution injected
The study was conducted after approval by the submucously into the upper and lateral parts of
institutional review board and informed written peritonsillar space bilaterally using a straight 23 G
consent from patients or parents. Fifty patients of both needle.
sexes aged 10-20 years, of ASA grade I and II requiring Each patient was assessed in PACU by an
tonsillectomy with or without adenoidectomy were investigator who was blind to group allocation. On
recruited for this prospective, randomized trial. The arrival in PACU, pain score and time to awaken (from
indications for surgery were either recurrent tonsillitis the end of anaesthesia until the patient opened the eyes
or hypertrophy with obstructive symptoms. Patients on command) were recorded. One hour after arrival
were excluded if they had any systemic disease, sensitive in PACU, pain at rest and on swallowing was assessed
to local anesthetic or had signs of acute pharyngeal using verbal analogue scale (VAS) of 0 10 (0 = no
infection. All patients had six hours of fasting and pain and 10 = unbearable pain). If pain score was more
received standard pre-medication and general than 5 at rest, diclofenac 1mg/kg was given IV/ IM, to
anaesthesia. Anaesthesia was induced by Pentothal reduce pain score to d3. Gag reflex was assessed by
sodium and fentanyl, intubated under atracurium and lightly touching posterior oropharynx with a tongue
maintained on O2, N2O and isoflurane. Fentanyl and depressor and the response was noted objectively on
atracurium were repeated when required. Tonsils were an arbitrary scale (None no response, Mild grimace
removed via monopolar electro-cautery by an but tolerable, Moderate facial flushing and Severe
experienced otolaryngologist (standard dissection facial flushing with cough, restlessness).
method). Adenoids were removed using a curette.
On transfer to ward, all patients were offered fluid
Hemostasis was done with suction, suturing and packs
two hours after surgery and VAS at drinking fluid was
as needed.
noted. Pain score at rest and swallowing were also
The patients were randomly divided into two recorded 1, 4, 8 and 12 hours after surgery. Oral
equal groups using random number table. At the
analgesic (paracetamol) was started 8 hours after surgery.
conclusion of surgery but before extubation, group GN
Time of 1st analgesic after surgery and adverse effects
patients (n=25) received bilateral glossopharyngeal
like nausea, vomiting, foreign body sensation and upper
nerve block (GNB) under direct vision using Mclvor
airway obstruction were noted and managed
gag by 1.5 ml of 0.5% bupivacaine with 1:200,000
accordingly.
adrenaline on each side. Group PT patients (n=25)
received bilateral peritosillar infiltration with 3 ml of The sample size of minimum 50 patients (25 per
Vol.-10, Issue-II, July-Dec - 2016
0.5% bupivacaine with 1: 200,000 adrenaline each side. group) was calculated on the basis of VAS during
After giving the block, the patients were extubated after swallowing. A difference of two between the groups
checking bleeders and were shifted to post anaesthesia were considered significant to have a power of 80% at
care unit (PACU) in left lateral position after observing = 0.05 (two tailed). Pain scores were compared by
for 10 minutes in the operation room. repeated measures analysis of variable ANOVA. Other
Glossopharyngeal nerve was blocked intraorally data were analyzed using X2 test when appropriate.
using the technique as described by Park et al (2007)[10]. Fisher exact test was used to analyze gas reflex test,
A 25 gauge spinal needle was angled to 450 at 1 cm from values were considered significant if p< 0.05. Patient
the tip. The needle was inserted at the middle point of characteristic, operative time and time delay between
posterior tonsillar pillar (Palato-pharyngeal fold), block/infiltration and need of supplementary analgesic
piercing the retropharyngeal mucosa. The needle was was analyzed using two tailed paired t test.
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DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.2
Table I :Patient demography and other data. Table III: Analgesia requirement, response to gag
reflex and adverse effects.
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DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.2
pain scores were lower in group GN compared to relieving pain on rest, swallowing and on first liquid
group PT between one and eight hours after surgery. ingestion.
The results of this study are consistent with those who Common complications related to GNB are upper
performed GNB for management of post-tonsillectomy airway obstruction (UAO), dyspnoea and foreign body
pain[6,10,12]. Glossopharyngeal nerve supplies most of the sensation in mouth. Peritonsillar infiltration also has
sensations responsible for pain transmission following some risks including bilateral vocal cord paralysis for
tonsillectomy[6]. Therefore glossopharyngeal nerve itself few hours and upper airway obstruction etc8 .We found
should be blocked to have effective pain control. To UAO in one patient who was an eleven years old boy
determine success of GNB, we evaluated response to with history of obstructive symptoms. He became
gag reflex which decreases after successful block[10]. The agitated just after he was extubated, had respiratory
degree of obtunded gag reflex indicates how successfully distress and oxygen saturation started falling. He was
glossopharyngeal nerve is blocked. Our observations managed with jaw thrust, 100% O2, oropharyngeal
demonstrated that the pain relief was better in patients airway and positive pressure ventilation. The patient
where gag reflex was absent or only mild. improved after a few minutes. He was shifted to PACU
In contrast to our results some authors have after keeping under observation for 10 minutes. UAO
reported that GNB was not effective for pain is a serious complication of GNB. It is presumed to be
management often tonsillectomy[9,13,14]. This could due to use of high volume and concentration of local
possibly be due to the fact that local anaesthetics did anaesthetic in the confined space ie lateral pharyngeal
not reach nerve terminals corresponding to the tonsillar space[19]. This may lead to blockade of vagus nerve
area. As none of these reports assessed success of block proximal to origin of recurrent laryngeal nerve or
by observing obtundation of gag reflex[10]. blockade of hypoglossal nerve. Both these nerves lie in
Previous studies regarding analgesic efficacy of peri- close proximity to glossopharyngeal nerve in lateral
tonsillar infiltration of local anaesthetic have reported pharyngeal space[13,19].
conflicting results. A systemic review concluded that In summary this study demonstrated the
there is no evidence that use of peritonsillar infiltration superiority of GNB in relieving post tonsillectomy pain
improves analgesia after tonsillectomy[15]. El -hakim over peritonsillar infiltration. Also, extent of obtunded
etal[14] demonstrated that infiltration of lignocaine along response to gag reflex strongly correlated with post-
with pethidine provided considerable pain relief after operative pain. GNB is easy to perform, but a note of
tonsillectomy. Other studies also reported similar caution is necessary before arguing for recommending
findings with other local anaesthetic bupivacaine[16]. On this block for post-tonsillectomy pain as some
the contrary several workers[7,8,17,18] failed to find any complications like UAO may be life threatening[13].
beneficial effect of peritonsillar infiltration. The results Therefore it necessitates careful selection of patient and
of our study are not very encouraging for patients who volume and dose of local anaesthetic and close
received peritonsillar infiltration for postoperative pain observation in the immediate post anaesthetic period.
relief. We found that 11 /25 patients in infiltration DISCLOSURES:
group needed rescue analgesic within one hour after
Vol.-10, Issue-II, July-Dec - 2016
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DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.2
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