Tonsillectomy practice in South Africa.
|Article Type:||Letter to the editor|
|Publication:||Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0256-9574|
|Issue:||Date: Feb, 2011 Source Volume: 101 Source Issue: 2|
|Topic:||Event Code: 200 Management dynamics|
|Geographic:||Geographic Scope: South Africa Geographic Code: 6SOUT South Africa|
To the Editor: Tonsillectomy is a very common operation done by ENT
surgeons and general practitioners in South Africa. Our impression is
that the procedure and its peri-operative care vary greatly. We
conducted a web-based survey (approved by the UCT ethics committee) to
evaluate tonsillectomy practice among South African ENT surgeons and
discuss the findings in relation to evidence-based practice from the
literature. We report only on the controversial and interesting aspects.
Ninety-three surgeons (27% of the ENT surgeons in active practice in
South Africa) completed the survey, of whom 65 were in private practice.
Method of tonsillectomy. Sixty per cent of both public and state surgeons remove tonsils by conventional cold steel dissection, which has a lower bleeding rate than more recent techniques such as coblation and bipolar dissection. (1)
Corticosteroids. Forty-seven per cent of surgeons use perioperative steroids. A Cochrane Library report includes Grade A supporting evidence that a single intravenous dose of dexamethasone is effective, relatively safe and inexpensive in reducing morbidity (pain, nausea and vomiting). (2)
Antibiotics. Sixty per cent of surgeons prescribe antibiotics, of whom 42% prescribe amoxicillin/clavulanic acid (Augmentin) and 38% amoxicillin. Although many surgeons believe these prevent postoperative bleeding, this is not supported by the literature. (3)
Local anaesthesia. Seventeen per cent of surgeons inject the tonsil bed with local anaesthetic. Although not believed to benefit postoperative pain, the latest systematic review seems to show a modest reduction in postoperative pain, and we suggest it as an adjunct to the normal analgesia. (4)
Postoperative pain. Tonsillectomy patients experience a great deal of pain. The mean time for cessation of pain is 11 days; (5) most surgeons (80%) agreed with this. Eighty-nine per cent of respondents warned their patients about the 5-6-day 'dip', when patients typically called their surgeon and reported that pain had increased, and that they couldn't eat, had become pyrexial and wished to visit the surgeon. There is only one report about this 'dip', in the journal Pain, which simply stated that pain declines after 3 days, but that 30% of the sample population made an unscheduled stop at the doctor between days 4 and 7. (6)
Postoperative chewing gum. Forty-nine per cent of surgeons advised patients to chew gum to reduce masseter muscle spasm and relieve pain. Only one study could be found that addressed this issue, which reported that chewing gum increased pain and that resumption of a normal diet was delayed. (7)
Postoperative diet. This created the most debate in the survey. Thirty per cent of surgeons prescribed a 'normal' diet, and the remainder advised diets ranging around chips, Nik Naks-type snacks, avocados, pawpaws (Natal graduates) and biltong (particularly Gauteng graduates); others advised patients to avoid 'acidic' foods, bananas and fruit juices. Reasons for prescribing the particular diets included 'experience'; 'patients must eat to prevent bleeding'; 'hard things get stuck in the tonsil bed'; and 'acid burns the tonsil bed'. No publications could be found relating to dietary advice.
Tonsillectomy is a commonly performed operation, and has significant morbidity relating to pain, yet peri- and postoperative pain management practices vary considerably, with little evidence to support some of these practices. Cold steel dissection and intraoperative steroids can be recommended, based on our literature review.
J J Fagan
Division of Otolaryngology
University of Cape Town
(1.) National Prospective Tonsillectomy Audit. London: The Royal College of Surgeons of England, 2005. http://www.rcseng.ac.uk/publications/docs/ national_prospective.html?searchterm=tonsillectomy+ (accessed 9 January 2011).
(2.) Steward DL, Welge JA, Myer CM. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2003;(1):CD003997.
(3.) Dhiwakar M, Clement WA, Supriya M, McKerrow WS. Antibiotics to reduce post-tonsillectomy morbidity. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005607.
(4.) Grainger J, Saravanappa N. Local anaesthetic for post-tonsillectomy pain: a systematic review and metaanalysis. Clin Otolaryngol 2008;33(5):411-419.
(5.) Salonen A, Kokki H, Nuutinen J. Recovery after tonsillectomy in adults: a three-week follow-up study. Laryngoscope 2002;112(1):94-98.
(6.) Warnock FF, Lander J. Pain progression, intensity and outcomes following tonsillectomy. Pain 1998;75(1):37-45.
(7.) Hanif J, Frosh A. Effect of chewing gum on recovery after tonsillectomy. Auris Nasus Larynx 1999; 26(1):65-68.
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