Critical Analysis of Research: Journals on Tonsillectomy
Abstract
The three articles all discussed and provided relevant explanations on the different strategies on how to alleviate pain related to tonsillectomy. One of the articles tested two different techniques on how tonsillectomy should be done to patients, by lessening the sound of their snoring. The two techniques include the coblation-assisted uvulopalatoplasty with tonsillectomy or CP and the standard palatoplasty technique, the KTP LAUP. Results indicate that the use of CP enables participants to experience more painful post-operative recovery but more controlled snoring.
Similarly, the post-operative pain management in participants was also the second article through provision of analgesia. Post-operative pain management in this article involves seeking to decrease nausea, pain, and vomiting, with which have been achieved through provision and administration of dexamethasone. In addition to the effective action of the analgesia to the post-operative pain management of participants, using dexamethasone was also said to be economic, and produced no known adverse side effects to the participants.
The third and final article used in this paper also aimed to help participants to manage pain associated with tonsillectomy through regional nerve blocks. In order to see the effect of nerve blocks to pain, three groups were studied, namely, the group administered with bupivicaine, saline, and the group with no injection.
Content
Abstract 1
Contents 2
Introduction 3
Justification of Selection of the Articles for Primary Research 4
Analysis of Evidence 5
1. Randomized-controlled study comparing post-operative pain 5
between coblation palatoplasty and laser palatoplasty
by Belloso et al (2006)
2. Use of intravenous steroids at induction of anesthesia 7
for adult tonsillectomy to reduce post-operative nausea
and vomiting and pain: a double-blind randomized
controlled trial by McKean et al (2005)
3. A randomized controlled trial of the effect of regional nerve 9
blocks on immediate post-tonsillectomy pain in adult
patients by El-Hakim et al (2000)
Factors influencing implementation of findings 11
Conclusion 13
References 15
Introduction
It has been reported that tonsillectomy is the most common ENT ward operation that has traditionally required overnight stay among patients (Dennis et al 2000). It has now prevalent in many individuals due to different medical reasons, such as snoring, bacterial tonsillar infections, chronic tonsillitis that is not responding to medical management and antibiotics, the presence of obstructive sleep apnea syndrome or OSAS, difficulty swallowing because of the enlarged tonsils, or the suspicion of tonsillar malignancy (Loury and Schaffer 2006). Because anybody can experience such causes or symptoms, anybody is susceptible to undergoing tonsillectomy. Thus, the main reason for choosing the topic is to gather relevant knowledge on how to help patients manage post-operative pain due to tonsillectomy.
Tonsillectomy is done through surgery under general anesthesia, such as through dissection, coblation, and bipolar diathermy (Yung 2000). This also involves the use of laser, which hastens recovery and healing. Because the process of tonsillectomy involves a painful procedure, nursing practitioners play an important role in post-operative pain management. This is because nurses, given the knowledge and skills to care for their patients effectively and appropriately, would be able to provide adequate and effective care and attention to their patients, particularly, with regards to their condition.
Justification of Selection of the Articles for Primary Research
It has been reported that primary research or field research involves gathering data that have not been existing in the previous body of knowledge. In order to gather the needed data, different methods can be used, including direct observation, experimentation, surveys (‘Primary Research’ 2008), and interviews. In this regard, it can be understood that primary research is being done by actually making a new research or study that no one has ever done before and gathering data from participants or respondents directly. Based on the three articles being referred to, it can be perceived that the authors have been successful in making its primary research regarding post-operative pain management in relation to tonsillectomy. The studies used large numbers of participants in order to support their pilot study. This is because by using large numbers of participants, results and findings of the studies will be appropriately justified.
Moreover, all the studies discussed different strategies that can be used for post-operative pain management in relation to tonsillectomy. Because it featured varied techniques in post-operative pain management, it discussed and provided varied results and opinions regarding managing tonsillectomy. The articles did not mention that their study has been based from other studies, thus, making their studies legitimately primary. In relation to this, the studies provided useful and relevant results and findings that can be based upon and used by other studies or researches in the same field. It also offered suggestions or recommendations on how the studies can be improved, in order to effectively and appropriate assess post-operative pain management, which can be used for future practical applications. In this regard, it can be understood that all the three articles have been successful in communicating their ideas and opinions to the readers, through their experiments, direct observation, and interviews.
Analysis of Evidence
1. Randomized-controlled study comparing post-operative pain between coblation palatoplasty and laser palatoplasty by Belloso et al (2006)
Method. This study used a single blind randomized trial, which means that the researcher knows the details of the treatment but the patients or respondents do not, thus, in this sense, the researcher can treat the patient differently, influencing the outcome of the study (‘Randomized Control Trial’ 2008). It has been indicated in the study that the study population consisted of patients undergoing uvulopalatoplasty, and no further contact between the patients and the researchers was allowed. The randomization was predetermined by computer random-generated number (Belloso et al 2006).
Sample. In order obtain the sample population, inclusion criteria were given emphasis, namely, simple snoring, participants with age of over 18 years, having the ability to understand the study, along with obtaining consent, having no cardio-vascular or chronic respiratory disease, diabetes, hematological and neurological disorders, no regular use of analgesia, and no concomitant surgery. The study population consisted of 17 patients in the CP group, with 13 males and 4 females, and the LAUP group consisted of 13 patients, with 9 males and 4 females (Belloso et al 2006).
Data Collection. The needed data was collected by setting up two different groups, namely, the CP group and the LAUP group. In the CP group or the coblation-assisted uvulopalatoplasty with tonsillectomy group, the surgical procedure was performed under microscopic vision using an ArthroCare Evac. A routine coblation tonsillectomy was done using settings 6 and trimmings of the soft palate/uvula and triangular submucosal resection of the soft palate using settings 7-8. On the other hand, in the LAUP group or the standard palatoplasty technique, the surgical procedure was limited to an excision of the soft palate/uvula and triangular submucosal resection of the soft palate, without tonsillectomy. A KTP/532 Laser was used, with a delivered energy of 12W in a continuous exposure mode (Belloso et al 2006).
Data Analysis. It has been indicated in the study that in the CP group, tonsillectomy in the surgical resection was included, which was not present in the LAUP group. It has been stated that the addition of tonsillectomy to palatoplasty produced a better reduction of snoring and OSAS. Although the process is more painful and takes a long time for recovery, better long-term snoring control was achieved. On the other hand, more severe muscular and mucosal damage have been observed in the LAUP group due to thermal tissue injury caused by laser. This caused delay in the healing process of the participants in the LAUP group and caused them discomfort (Belloso et al 2006).
Findings. Findings of the study stated that both surgical techniques proved to be adequate options in the treatment of snoring, which is one of the causes for tonsillectomy, as both produced similar early post-operative reduction of snoring. However, the LAUP group had better long-term results compared to the more mutilating surgery involved in the CP group, although the CP group were expected to produce greater decrease in snoring loudness. This was due to the fact that the LAUP group had thermal injury inflicted by the laser, which increased scaring and tightening of the soft palate, thus, causing decrease of palate mobility and reduction of snoring level (Belloso et al 2006).
2. Use of intravenous steroids at induction of anesthesia for adult tonsillectomy to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial by McKean et al (2005)
Method. This study was a double-blind, randomized, prospective trial, which means that not all researchers know the series of numbers involved in the treatments of the participants, thus, not making the treatment known to the patients. A more realistic distribution of the sexes and ages of the patients can be achieved, thus, giving more accurate results (‘Randomized Control Trial’ 2008). In order to observe ethics, approval was obtained from the Local Research Ethics Committee to make sure that probable risks and problems are considered against expected advantage for the individual trial subject and for the entire society (McKean et al 2005).
Sample. Seventy-two consecutive patients were considered for the study, which have met the inclusion criteria, and were enrolled in a 10-month period. However, only 24 participants returned considerable results. Inclusion criteria included age 16-70 years, ASA score 1 and weight 50-100kgs. Exclusion criteria of the participants include presence of suspected diagnosis of malignancy, both of which for unilateral tonsillectomy and contraindications to the use of non-steroidal and anti-inflammatory drugs (McKean et al 2005).
Data Collection. The 24 participants were divided into two groups, namely, the control and the trial group. The control group, which consisted of 22 participants received 2mL of normal saline intravenously at induction of anesthesia, while the trial group, which consisted of 24 participants received 10mg or 2mL of dexamethasone intravenously at induction of anesthesia. The trials include analyzing three areas, including pain, PONV, and time taken to ingestion of food and diet (McKean et al 2005).
Data Analysis. Results of the study suggest that there was no significant difference in terms of PONV and first ingestion of food and drink in both groups. However, the difference in the two groups lies on their pain scores. It has been stated that the pain scores of the trial group were lower than the pain scores of the control group. In addition, this was further supported by the fact that the pain scores were significantly lower for the day of operation, and the other days consecutively. It was reported that oftentimes, the most pain is felt after tonsillectomy, during the second and third days after the operation. In the trial group, where dexamethasone was administered, inflammation of the operative site was reduced, thus, reducing the release of inflammatory mediators into the circulation, and in turn, lead to lesser stimulation of the vomiting center (McKean et al 2005).
Findings. Findings of this study suggest that a single dose of 10mg of dexamethasone, given intravenously at induction of anesthesia to the participants in the trial group, due to adult tonsillectomy decreased the pain scores to the day of operation. In addition, in the trial group, post-operative nausea and vomiting was also reduced significantly for the day of operation. Moreover, the mean pain scores for the participants in the trial group were significantly lower compared to the mean pain scores of the control group. There was also no significant difference between the time to first ingestion of food and drink and PONV. More importantly, economic benefits have been said to be achieved with reduced need for analgesia and anti-emetics, and no adverse side effects were observed among participants (McKean et al 2005).
3. A randomized controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients by El-Hakim et al (2000)
Method. A stratified block randomization method was used to ensure equal and balanced allocation of patients according to sex to the groups at all times, and men and women were randomized independently in blocks of three. This process was organized in each two centers separately using computer generated random number tables. The clinical trials were run in the otolaryngology departments of two teaching hospitals, namely Aberdeen Royal Infirmary and Ninewells Hospital and Medical School. Similar to the other two studies, ethical committee approval was also sought in both centers (El-Hakim et al 2000).
Sample. Adults patients over the age of 16 years suffering from chronic or recurrent acute tonsillitis and listed for tonsillectomy were recruited. Participants were excluded if they had a history of chronic pain, alcohol abuse, hepatic disease, cardiac disease, seizures, or allergy to amide anesthetics. In addition, patients who used analgesia within 48 hours or those who used systemic antibiotics within 7 days prior to tonsillectomy were also excluded. The study also excluded patients with a history of a peritonsillar abscess or a recent attack of acute pharyngitis (El-Hakim et al 2000).
Data Collection. It has been stated that two surgeons performed the procedures using a bipolar diathermy tonsillectomy technique, and a standard anesthetic technique. Ninety-two participants were considered for the study and were divided into three separate groups. The bupivicaine group, which comprised of 29 patients, received 5mL of 0.5% bupivicaine. The second group, the placebo group, which is comprised of 30 patients, received a ‘placebo’ injection 0.9% saline employing the same volumes and injection technique. Lastly, the third group is the no injection group, which is comprised of 33 patients, received no injection. In addition, in order to administer the nerve blocks, an angled tip needle, 1cm long, is introduced at the midpoint of and 0.5cm behind the posterior tonsillar pillar. It was directed laterally and lie between the superior and middle constrictors of the lateral pharyngeal wall, which is adjacent to the nerve. Moreover, the lesser palatine nerve block was performed by introducing a needle, which is placed lateral to the base of the uvula in order to raise on infiltration a mucosal fold in the supratonsillar fossa (El-Hakim et al 2000).
Data Analysis. Analysis of the obtained data suggests that the sex, weight, and age distribution of the patients in all three groups did not create significant differences. No significant difference was also observed in terms of the post-operative pain scores of all participants in three groups. In addition, the consumption of analgesics of patients in three groups was the same, along with their blood pressure values. However, some of the patients in all three groups developed a secondary post-tonsillectomy bleed. No other side effects or complications were indicated (El-Hakim et al 2000).
Findings. Findings of the study indicate that patients in the bupivicaine group experienced more severe pain in the morning after surgery compared to the patients belonging to the two other groups. This means that adults who undergone tonsillectomy do not derive benefits from the use of bupivicaine in their aim to block the glossopharyngeal and lesser palatine nerves (El-Hakim et al 2000).
Factors influencing implementation of findings
Based on the findings of the three articles, it can be perceived that such findings can help the advancement of the field of tonsillectomy, particularly the individuals that undergo the process. However, different factors influence how they can be implemented. One of such factors includes the practices, behaviors, skills, and knowledge of the nurses or health practitioners. Because they are the ones responsible for the treatment of the patients, they must have adequate knowledge and skills regarding the process. However, such relevant and useful findings cannot be implemented if the knowledge and skills of the health care practitioners would not be able to support the techniques they would use. This is then related to their faulty administration of the technique, thus, resulting to disastrous consequences. Another factor to consider is the lack of effective communication between experts, which does not help clarify the right process of the use of the technique. The third factor is the wrong misconceptions and practices of the patients, which either worsens their condition or put them at risk of undergoing tonsillectomy. The lack of communication with healthcare practitioners leads them to observe practices that affect them significantly. The fourth and final factor to consider is the lack of funds or support from the government or from the individuals that must be concerned in helping to find the evidences for the techniques. The lack of funds and support hinders such relevant findings to be implemented because the number of participants, time to accomplish the study, and the techniques to be used will all be limited, based on the available funds.
In this sense, the primary recommendation is to seek for funds or support from the government so that adequate funds for the accomplishment of the study can be achieved. Through adequate support and funding, the materials, methods, participants, and time involved in the study would be sufficient in order to produce accurate, relevant and useful findings. In line with this is the second recommendation, which is to suggest that more researches must be done in order to gather evidences and data to support the existing body of knowledge. This would also help add to the existing knowledge regarding tonsillectomy and correct the wrong findings or misconceptions about it. Through more researches, updating the existing findings of the researches would be done, in line with the advancement, improvement, and development of today’s technology, communication, and science. In this sense, it would be easier for healthcare practitioners to assess the right technique or strategy for a more effective tonsillectomy process. This would also be helpful for patients in post-operative pain management. The third recommendation is providing improved education and training to all healthcare practitioners, in order to assist the nurses to implement effective healthcare to patients. Through effective education, communication among the healthcare practitioners and communication with their patients would also be achieved, thus, enabling more effective treatment and healthcare.
Conclusion
From the discussion, it can be deduced that the process of undergoing surgical tonsillectomy is a tedious and painful process that would require the cooperation, support, and concern of the patients and the healthcare practitioners as well. Three journal articles were given emphasis, which all aimed at helping patients manage post-operative pain in relation to tonsillectomy. Similarly, all these three articles came up with different strategies or techniques that aimed at post-operative pain management of patients that had undergone tonsillectomy. The three articles came up with separate findings that can be practically used in actual cases and can be used as bases for other researches.
However, although the findings of the articles were equally relevant and useful, a number of factors possibly impede the use or implementation of such findings in actual situations. Among the factors that limit the implementation of the findings include the lack of government funding and support, the lack of communication, knowledge, and skills of healthcare practitioners and patients, and the lack of more researches and evidences to support the effectiveness of the findings. As such, recommendations include provision for funds and support from the government, improvement and development of education and training of healthcare practitioners, education and communication with patients, and coming up with more researches on the field.
References
Belloso, A, Morar, P, Tahery, J, Saravanan, K, Nigam, A and Timms, MS 2006, ‘Randomized-controlled study comparing post-operative pain between coblation palatoplasty and laser palatoplasty’, Clin. Otolaryngol, vol. 31, pp. 138-143.
Dennis, S, Georgallou, M, Elcock, L and Brockbank, M 2000, ‘Day Case Tonsillectomy – The Salisbury Experience’, The Journal of One-Day Surgery, vol. 14, no. 2, pp. 17-22.
El-Hakim, H, Nunez, DA, Saleh, HA, Macleod, DM and Gardiner, Q 2000, ‘A randomized controlled trial of the effect of regional nerve blocks on immediate post-tonsillectomy pain in adult patients’, Clin. Otolaryngol, vol. 25, pp. 413-417.
Loury, MC and Schaffer, SB 2006, Advanced Otolaryngology, viewed 25 March 2008, <http://www.drlouryent.com/Pages/PatientServices/1066.html>.
McKean, S, Kochilas, X, Kelleher, R and Dockery, M 2006, ‘Use of intravenous steroids at induction of anaesthesia for adult tonsillectomy to reduce post-operative nausea and vomiting and pain: a double-blind randomized controlled trial’, Clin. Otolaryngol, vol. 31, pp. 36-40.
O’Deane, KH 2006, Randomized Controlled Trial Design, British Journal of Occupational Therapy, vol. 69, no. 5
O’Deane, KH 2006, Randomized Controlled Trial Reporting, British Journal of Occupational Therapy, vol. 69, no. 6.
Polit, DF and Beck, CT 2006, Essentials of Nursing Research: Methods, Appraisal, and Utilization, 6th ed., Lippincott Williams & Wilkins, Philadelphia.
‘Primary Research’ 2008, Wikipedia, the Free Encyclopedia, viewed 25 March 2008, <http://en.wikipedia.org/wiki/Primary_research>.
‘Randomized Controlled Trial’ 2008, Wikipedia, the Free Encyclopedia, viewed 25 March 2008, <http://en.wikipedia.org/wiki/Randomized_controlled_trial>.
Yung, M 2000, ‘Report of a National Survey of Tonsillectomy’, pp. 1-11.
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