Tonsillectomy is one of the most frequently performed ambulatory surgical procedures.¹ The introduction of an electrodissection surgical technique has virtually eliminated immediate postoperative hemorrhage. However, it may cause more pain, discomfort and poor oral intake due to more local inflammation, nerve irritation and laryngeal muscle spasm.² Pain is still the most significant obstacle to the rehabilitation of a patient following tonsillectomy.

Post tonsillectomy pain has a maximum intensity immediately after operation and in the first three post operative days.³ Thus there is a need to achieve adequate pain control. Various strategies for the management of post tonsillectomy pain have been proposed like infiltration of local anaesthetic,^4,5 non-steroidal anti-inflammatory drugs (NSAID)⁶, narcotics and oral analgesics⁷. Application of sucralfate as a protective barrier following tonsillectomy has been found to promote healing with significant pain reduction in the post-operative period.⁸

The aim of this study was to compare the efficacy of pre-operative local infiltration of local anesthetic (bupivacaine) with the conventional parenteral administration of an NSAID, diclofenac sodium, on postoperative pain in adults undergoing tonsillectomy using a standardized anesthetic technique.

This study was conducted in the Department of Otorhinolaryngology, royal medical services, Jordan, in the period from June 2003 to July 2005.

After an informed written individual consent was taken, 120 patients of either sex, age 20 to 40 years posted for tonsillectomy were enrolled the indication being chronic tonsillitis, recurrent episodes of acute tonsillitis.

Cases of peritonsillitis, peritonsillar abscess, neoplastic lesions, patients with a known allergy to the drugs being used, asthma, kidney, or hepatic dysfunction or hemorrhagic diathesis were excluded.
Patients were randomly assigned to each group using a list of random numbers, and received either of the two treatment modalities.

Group A: Received diclofenac sodium 1.5 mg/kg intramuscular, 30 min. before surgery (60 patients).
Group B: Received bilateral pre-incisional infiltration of 3 ml of 0.25% bupivacaine in the peritonsillar fossa (60 patients).

All the tonsillectomies were performed using a standardized anesthetic technique. One surgeon employed the blunt dissection technique (Boyle-Davies). The bleeding was controlled by bipolar diathermy or ligation.

Pain was estimated in all patients by an independent observer. Visual analogue score (VAS) was assessed on a 0- 100 mm scale ( 0 mm: no pain; 100 mm : maximum imaginable pain) and estimated at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery.

There was no significant difference in demographic data between the two groups.
The mean post-operative pain scores for group A at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery were (26.25±6.66, 32.00±5.47, 30.50±4.84, 14.25±4.37, 9.5±1.53) respectively.
The mean post-operative pain scores for group B at 1 hour, 3 hours, 6 hours, 12 hours and 24 hours after surgery were (28.50±4.89, 32.00±4.47, 30.57±4.84, 17.25±5.97, 8.7±1.37) respectively.
There was no statistically significant difference between group A and B at all time intervals (p< 0.01).

The reduction of post-tonsillectomy pain is important not only for patient comfort, but also because reducing pain improves oral intake, reduces the risk of dehydration, infection and post surgery hemorrhage. ⁹

Throat pain, referred otalgia and bleeding after tonsillectomy contribute to making recuperation difficult and prolonged. Therefore adequate analgesia is necessary to relieve the agony of pain and reduce incidence of bleeding since increased vascular congestion of the head and neck associated with crying may precipitate bleeding10. The most common method of providing postoperative analgesia is systemic administration of narcotic analgesics though these drugs have their own side effects.
Post tonsillectomy pain is probably the result of muscle spasm caused by inflammation and irritation of the pharyngeal musculature. ⁸

Bupivacaine is an amide- linked local analgesic. It was synthesized by Ekenstan in 1957 and has been used extensively in obstetric practice to produce epidural analgesia and peripheral nerve blockade in the management of intractable pain. Its high lipid solubility and protein binding, results in rapid onset of action and prolonged duration (6-9 hours). The recommended upper limit of safe dosage of bupivacaine is 2mg/kg body weight.¹¹ Systemic toxicity produces arrhythmia, drowsiness, convulsions, paraesthesia, disorientation and nystagmus.

Diclofenac sodium 1 mg/kg intramuscular, given after induction of anaesthesia was found to be an effective alternative to opiates in tonsillectomy patients. ⁷
During surgery, pain impulses entering the central nervous system, create a hyperexcitable state inspite of general anaesthesia. Blockade of these impulses by preoperative analgesic drugs¹² or infiltration of local anaesthetic agents has a pre-emptive analgesic effect.⁴ Therefore we planned to give parenteral diclofenac and local infiltration before the tissue trauma.

Our results showed that Preoperative diclofenac in group A and preincisional infiltration in group B were found to be equally effective methods for treating post tonsillectomy pain.