Postoperative pain and bleeding after adenotonsillectomy versus adenotonsillotomy in pediatric obstructive sleep apnea: an RCT

Abstract

Purpose: Our previous randomized controlled trial (RCT) of children with obstructive sleep apnea (OSA) showed no significant differences between adenotonsillectomy (ATE) and adenotonsillomy (ATE) in improving nocturnal respiration and symptoms after one year. This is the continuous report with the evaluation of postoperative morbidity concerning bleeding and pain.

Methods: A double-blinded RCT including 79 children, aged 2-6 years, with moderate to severe OSA, randomized to either ATE (n = 40) or ATT (n = 39). From one to ten days postoperatively, parents filled in a logbook with six pain-related outcomes (parent and child grading pain at different levels, days of analgesic use and return to normal diet). Peri- and postoperative bleeding were also registered.

Results: 63 patients (80%) returned the logbook. There were significant differences between groups in only two of the six pain-related outcomes in favor of the ATT group; first day when the children graded themselves as pain free (p = 0.021, Log Rank Test), and first day the caregiver estimated pain VAS ≤ 5 (p = 0.007, Log Rank Test). Two (5%) cases of postoperative bleeding occurred in the ATE group, one of which needed a return to theatre. No case of postoperative bleeding was seen in the ATT group.

Conclusions: The results from this RCT are in line with previous comparative studies between ATT and ATE. Children operated with ATT had significantly less postoperative pain in one-third of the outcomes, and less bleeding than ATE. However, as the differences in morbidity between the surgical methods were minor the clinical significance is uncertain.

Trial registration: This study was approved by the Swedish Regional Ethics Board in Stockholm, Sweden (Dnr 2011/925-32 and 2013/2274-32) and registered at ClinicalTrials.gov (Trial registration number NCT01676181).

Keywords: Adenotonsillectomy; Adenotonsillotomy; Paediatric obstructive sleep apnea; Tonsillectomy; Tonsillotomy.

Conflict of interest statement

The authors declare that they have no conflicts of interest. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Figures

Fig. 1

Flow of participants

Fig. 2

Faces Pain Scale-Revised (FPS-R). https://www.iasp-pain.org/fpsr. Copyright© 2001, International Association for the Study of Pain®. Reproduced with permission

Fig. 3

a–f Log-Rank comparison of Kaplan Meier estimator for postoperative recovery for adenotonsillectomy (ATE dotted line) and andenotensillotomy (ATT solid line), with estimates of time (days) to pain-related outcomes. For all figures, the y-axis represents the proportion of the patients who are estimated as pain free (a + b), in reduced pain (c + d), no longer in need of analgetics (e) and returned to normal diet (f), at a given time. Patients were censored after 10 days since the log books contained no information thereafter. Two outcomes showed significantly lower pain in the ATT group compared to ATE (a, d)