Analgesia for adenotonsillectomy in pediatric patients: a narrative review

Introduction

Background and objective

Tonsillectomy and adenoidectomy are among the most commonly performed surgeries in the pediatric population. These procedures are typically performed to address adenotonsillar hypertrophy, sleep-disordered breathing, recurrent tonsillitis, and other related conditions (1). In the United States alone, around 300,000 to 500,000 tonsillectomies are performed each year on children under 15 years of age (2,3). The purpose of the review is to offer a comprehensive insight into pain management strategies, including pharmacological and non-pharmacological approaches. Most importantly, the review highlights Children’s Memorial Hermann Hospital current pain management approach for tonsillectomy and adenoidectomy. Therefore, the article is presented in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-31/rc).

Rationale and knowledge gap

Optimal postoperative pain management is essential for a smooth recovery, as suboptimal pain control can lead to adverse clinical outcomes. In 2019, the clinical practice guideline published by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) emphasized that oropharyngeal pain is the leading cause of complications following tonsillectomy (4). This pain can lead to reduced oral intake, dehydration, difficulty swallowing, sleep disturbances, behavioral changes, and, in some cases, hospital readmission (4).

Methods

A systematic search of Google Scholar, Embase, and PubMed was conducted, with additional searches on Google and Cochrane for gray literature. Key terms included “tonsillectomy”, “adenoidectomy”, “analgesics”, “pain management”, “postoperative pain”, “pediatric analgesia”, and “anesthesiology”.

Articles from the last 10 years, prioritizing the past 5 years, were included. Eligible studies were in English, addressed postoperative analgesic techniques in pediatric tonsillectomy/adenoidectomy, and discussed side effects and efficacy. Non-English articles, unrelated topics, editorials, and pre-2000 publications were excluded. Articles, especially those from the past 5 years, were qualitatively synthesized and independently reviewed, comparing standard practices with the authors’ institutional approach. An overview of the search strategy is included in Table 1.

Discussion

Pain management in adenoidectomy and tonsillectomy is crucial for patient recovery and comfort. Assessing pain in children is often more challenging than in adults, but certain indicators can help identify pain (5). Self-reporting is considered the “gold standard” in children who can communicate, allowing them to directly express the nature and intensity of pain (6). Validated tools, such as numeric rating for 7 years and older, FLACC (Face, Legs, Activity, Cry Consolability) scale (7 years and younger, developmentally or cognitively delayed patients who cannot verbalize), visual analog scales (VAS) and numeric rating scales, are also effective for children with the cognitive ability to understand and use them (7). Nonetheless, for children who cannot self-report, such as infants or those with cognitive impairments, behavioral observations such as facial expressions, crying, and body movements are reliable pain indicators. Observational tools, like the Non-communicating Children’s Pain Checklist-Revised (NCCPC-R), have been developed to quantify pain intensity based on these behaviors, providing a structured approach to pain assessment in non-verbal children (8,9). Furthermore, research indicates that painful memories from childhood can affect an individual’s future ability to cope with pain (10).

Studies have explored multimodal analgesia (MMA) that minimize opioid use while providing effective pain control. Non-opioid analgesics are the cornerstone of postoperative pain management in pediatric tonsillectomy and adenoidectomy, with acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) being administered in up to 92.7% of cases. Although opioids such as oxycodone, tramadol, and morphine may still be used in 4% to 48.2% of cases, their use has declined due to concerns about respiratory depression and other adverse effects. In addition to these, other pharmacologic agents like propofol, ketamine, and dexmedetomidine are occasionally employed, particularly in intraoperative or immediate postoperative settings, although data on their frequency of use is limited (11). Thus, studies have explored multimodal approaches combining non-opioid analgesics such as acetaminophen, ibuprofen, dexamethasone, and dexmedetomidine to optimize pain management (12). The growing preference for multimodal regimens combining non-opioids with adjuncts reflects current best practices to minimize opioid use while ensuring adequate analgesia and improving outcomes in the children.

Pharmacological strategies

Non-opioids

Acetaminophen

Acetaminophen is an extensively used analgesic because of its safety and efficacy in managing mild to moderate pain. It inhibits prostaglandin synthesis, reducing pain and fever (13). In 2010, the U.S. Food and Drug Administration (FDA) approved an intravenous (IV) formulation of acetaminophen in both adults and children aged 2 years and older (14). Standard dosing for acetaminophen (10–15 mg/kg every 4–6 hours) is the same for both IV and oral forms, though IV administration may provide a quicker onset of action (15).

A study by Lammer et al. in 2021 demonstrated IV acetaminophen in children provides a more significant opioid-sparing effect compared to oral acetaminophen, especially during the intraoperative and immediate postoperative recovery phases. Nonetheless, it must be taken into consideration that while IV acetaminophen may act more quickly, oral acetaminophen ultimately achieves similar analgesic outcomes over time. The study further compared preoperative oral loading dose (30 mg/kg) versus IV acetaminophen (15 mg/kg), which showed insignificant differences in perioperative severe pain scores, suggesting that oral acetaminophen can provide equivalent opioid-sparing effects during intraoperative and recovery phases compared to IV acetaminophen in pediatric patients (16).

Cost considerations are also important. IV acetaminophen is considerably more expensive than oral formulations, excluding additional costs for equipment and personnel (17). Therefore, optimizing the use of oral acetaminophen is advisable.

NSAIDs

NSAIDs are effective analgesics that reversibly inhibit cyclooxygenase (COX), the enzyme that converts arachidonic acid into prostaglandins and thromboxanes, mediating inflammation, pain and platelet adhesion (18,19). By impairing platelet function, NSAIDs can affect hemostasis, raising safety concerns in tonsillectomy (20).

Two systematic reviews, published in 2013 found no increased bleeding risk with NSAIDs though these reviews included studies of multiple different NSAID agents (21,22). Similarly, a 2024 systematic review of ibuprofen found no increased bleeding risk and reported better pain control with reduced nausea and vomiting (23). Other studies found no increased bleeding even with high-dose regimens of ibuprofen (24). While research on optimal timing is limited, a 2015 study showed effective analgesia with alternative acetaminophen and ibuprofen (25).

Ketorolac is a widely used NSAID for pain management in pediatric adenotonsillectomy; however, it remains controversial due to its association with post-tonsillectomy hemorrhage (PTH), a potentially life-threatening complication. The risk of PTH is age-dependent, with adolescents aged 11–17 years at a higher risk. Although several systematic reviews suggest ketorolac is safe, a Cochrane review by Lewis et al. (21) found that the available evidence is insufficient to exclude increased bleeding risk. Variations in surgical techniques across studies may also confound bleeding risk assessment. Intracapsular tonsillectomy is generally associated with less perioperative pain and a lower risk of PTH compared to the extracapsular method. Studies, including that of Kolb et al., reported no increased risk of PTH with ketorolac; however, such findings were limited to specific surgical techniques, including intracapsular tonsillectomy, electrocautery, and coblation. In contrast, a study by Shaikh et al. found that same-day ketorolac use in children undergoing tonsillectomy, with or without adenoidectomy, was associated with a significantly higher risk of both primary and secondary hemorrhage requiring operative intervention, an outcome more clinically relevant than self-limiting bleeding. This study reinforces concerns over ketorolac’s bleeding risk in the pediatric population and may influence perioperative pain management practices (26-28).

Evidence on diclofenac for post-tonsillectomy pain is limited. However, one retrospective study found no higher bleeding risk versus dihydrocodeine and a randomized controlled trial (RCT) demonstrated comparable analgesia to tramadol (29,30).

COX-2 inhibitors are a subtype of NSAIDs that specifically inhibit cyclooxygenase 2 (31). Evidence supports celecoxib use for post-tonsillectomy pain in both pediatric and adult populations. A recent meta-analysis showed that high-dose celecoxib significantly reduced postoperative pain without increasing bleeding or postoperative nausea and vomiting (PONV) (32).

In conclusion, evidence strongly supports NSAIDs for post-tonsillectomy pain control, with ibuprofen having the most favorable safety profile, consistent with the clinical practice guideline from the AAO-HNSF 2019. Caution is advised with ketorolac due to the potential increased bleeding risk. While promising results have been seen with celecoxib, further research is needed to fully assess the role of other NSAIDs in post-tonsillectomy pain management. As our understanding evolves, individualized approaches considering patient factors and specific NSAID properties may optimize pain control while minimizing risks (4).

Opioids

Opioids have been considered the gold standard for pain management (33). However, concerns about their use in the context of the opioid crisis have emerged (34). This has led clinicians to shift away from the administration and prescription of opioids in situations where other options exist (35).

Exogenous opioids like morphine, fentanyl, and oxycodone act via the µ-opioid receptors in the spinal cord and brain centers (primarily the somatosensorial cerebral cortex) involved in pain processing (36-39). While effective, opioids can depress respiratory centers and airway reflexes. Obstructive sleep apnea (OSA), common in tonsillectomy patients, heightens this risk (40). Furthermore, OSA marked by intermittent hypoxia can also trigger systemic inflammation and elevate proinflammatory cytokines, such as TNF-alpha (TNFα), interleukin-6 (IL-6), and interleukin-1 beta (IL-1β). These inflammatory markers are linked to increased pain perception and may enhance opioid sensitivity by sensitizing nociceptors, leading to hyperalgesia (41).

Traditionally, codeine was considered a first-line agent for pain relief after tonsillectomy (42). However, genetic variations in the CYP2D6 enzyme lead to significant differences in codeine metabolism. Ultra-fast metabolizers with multiple CYP2D6 gene copies rapidly convert codeine to high morphine levels, risking severe toxicity and life-threatening events like apnea, as seen in a post-tonsillectomy case (43). Additionally, opioid intoxication from codeine may occur when other factors, like CYP3A4 inhibitors or reduced kidney function, complicate metabolism (44). Risks are further highlighted by cases of infant death due to high morphine levels in breast milk from ultra-fast metabolizer mothers (45). Fast metabolizers generally relieve pain with lower toxicity risk, though monitoring remains important (46). Non-metabolizers who lack CYP2D6 activity produce minimal morphine, often requiring alternative pain management strategies (47).

Throughout the early 2000s, awareness of codeine’s potential respiratory risks and published case series, including deaths, led FDA to issue a black box warning against its use in tonsillectomy patients in 2013 (48,49). This marked a shift away from opioid, and in 2017, the FDA also listed tramadol as contraindicated for children undergoing tonsillectomy (50).

A study by Tsampalieros et al. in 2022 reviewed 374 children who underwent adenotonsillectomy and preoperative polysomnography. They found 17.6% of children experienced at least one postoperative respiratory adverse event (PRAE) in the PACU, requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. There was an observed independent interaction between the preoperative OSA severity and the use of postoperative morphine-equivalent dose. Additionally, the combination of previously mentioned factors also compounded the risk of PRAE. This suggests that children with more severe OSA face a higher risk of opioid-related complications (51).

Despite growing evidence risk factors associated with opioids, there remains a lack of robust data demonstrating that opioids provide superior analgesia compared to non-opioid alternatives. Oremule et al. conducted a two-cycle prospective audit comparing pain management with paracetamol and ibuprofen alone versus adding as-needed oral morphine, and found no significant change in initial pain profiles, worst pain scores, or rates of healthcare service contact. The morphine group also reported higher pain scores on the 7th postoperative day (52). Mann et al.’s retrospective study comparing opioid-free versus opioid anesthesia in pediatric adenotonsillectomy found no difference in PACU length of stay (146.68 vs. 143.18 minutes, P=0.586) and no difference in adverse events or readmissions. Notably, 73.4% of opioid-free patients needed no postoperative opioids. These results indicate that opioid-free anesthesia using IV acetaminophen alone or in combination with ibuprofen may be equally effective for pain management (53).

However, the evidence regarding opioid use in tonsillectomy is not entirely one-sided, particularly when considering adult patients. A comprehensive nationwide study by Alm et al. (11) on post-tonsillectomy analgesic regimens in Sweden revealed that adult patients who received opioids in addition to paracetamol and COX inhibitors reported significantly less dissatisfaction with pain relief compared to those who received only paracetamol and COX inhibitors (15.9% versus 25.9% dissatisfaction, P<0.001). Nevertheless, this effect was only observed in adult patients, not in pediatric populations. Furthermore, adults receiving opioids also reported more side effects (5.7% versus 2.7%, P=0.039). The study notes increased side effects with opioids but lacks details on opioid types, showing no evidence of superior pain control in pediatric tonsillectomy. This supports favoring non-opioid approaches for children while carefully weighing opioid use in adults (12).

A recent systematic review of clinical guidelines shows a cautious stance on opioid use, with most recommending them only for postoperative rescue analgesia. The AAO-HNSF and French Society of Oto-Rhino-Laryngology and Head and Neck Surgery (SFORL) advised against codeine, while the National Tonsil Surgery Register in Sweden (NTSRS) and AAO-HNSF recommended against tramadol due to respiratory risks. Only the NTSRS provided dosing guidance for morphine and oxycodone, and some guidelines, such as those from the French Society of Oto-Rhino-Laryngology and Head and Neck Surgery-French Association for Ambulatory Surgery-French Society of Anaesthesia and Intensive Care (SFORL-AFCA-SFAR), did not address opioids (54).

Methadone

Methadone, a synthetic mu-opioid receptor agonist has long been utilized for postoperative pain management in cardiac and spine surgeries. Recently it has gained popularity in other surgical procedures as well. In pediatric adenotonsillectomy, methadone may reduce pain, opioid consumption, and associated side effects; however, specific studies evaluating its efficacy in this context remains limited (55). A 2024 randomized double-blind trial by Einhorn et al. evaluated intraoperative methadone (0.1 or 0.15 mg/kg ideal body weight) versus fentanyl in pediatric tonsillectomy. Patients receiving 0.15 mg/kg methadone required fewer opioids during the first postoperative week, a key finding supporting its use for longer-lasting analgesia. Secondary outcomes, though not primary endpoints, showed reduced PACU use of dexmedetomidine and oxycodone, and a shorter PACU stay. While further research is needed, these findings suggest that intraoperative methadone may offer effective and sustained pain control with reduced postoperative opioid requirements (56).

There is an increasing move away from routine opioid use for post-tonsillectomy pain, particularly in pediatric patients, as codeine and tramadol carry significant respiratory risks. Non-opioid regimens often provide equally effective pain relief, though carefully selected adult patients may still benefit from limited opioid use. Opioids should generally be avoided in children and patients with sleep-disordered breathing but can be considered as rescue therapy in monitored settings such as the PACU. Pain management should be individualized to balance safety and efficacy, and further research is needed to refine opioid use and optimize best practices.

Intra-operative anesthetics

Propofol

Propofol is a rapidly acting IV sedative and anesthetic agent widely used in surgical procedures. It provides effective sedation, anticonvulsant properties, and rapid onset and recovery (57). One study demonstrated propofol-based anesthesia to be associated with significantly lower postoperative pain scores and reduced agitation compared to sevoflurane. This was particularly evident in the early postoperative period, where propofol also reduced the need for additional analgesics like acetaminophen (58). Furthermore, the use of propofol infusion in pediatric intensive care settings has also shown a reduction in the need for other pain and sedation infusions, suggesting its efficacy in managing postoperative pain (59). However, currently, further research is required to determine the significance of these findings.

Ketamine

Ketamine is an N-methyl-D-aspartate (NMDA) and glutamate receptor antagonist with potent analgesic, sedative, and amnestic properties (60).

For 65 years, ketamine has been a widely used IV anesthetic, inducing dissociative anesthesia characterized by a trance-like state with catatonia, analgesia, and amnesia. Patients maintain open eyes with preserved reflexes, minimizing airway obstruction risks, and experience detachment with altered sensory perceptions. Its sympathomimetic effects, which elevate both blood pressure and heart rate, make it a valuable option for managing hypotension or shock in emergency situations. Versatile in administration routes, primarily IV and intramuscular (IM), ketamine is particularly useful in pediatrics for children with congenital heart disease and is also commonly used in head and neck surgeries (61).

In contrast to opioids, ketamine does not abolish airway reflexes and does not depress respiratory drive, making it an attractive agent for the tonsillectomy patient group. Multiple studies have investigated the efficacy of ketamine for post-tonsillectomy pain management, primarily in pediatric populations. The majority of these trials have demonstrated positive outcomes, with reduced postoperative pain (61-66).

A 2023 network meta-analysis by Kim et al. evaluated peri-tonsillar agents, providing insights into the efficacy of peritonsillar ketamine. Ketamine ranked second for 1-day postoperative pain relief after peritonsillar tramadol and significantly prolonged the time to first analgesic use while reducing the total number of analgesic doses required compared to placebo. It also showed the lowest incidence of PONV, although this effect did not reach statistical significance (67).

Growing evidence supports the use of ketamine as a safe and effective analgesic for post-tonsillectomy pain management (68). Both systemic and local administration of ketamine have been shown to reduce pain scores and analgesic requirements, with efficacy comparable to opioids. Ketamine’s favorable safety profile and the promising results of peritonsillar administration further support its potential. However, standardized protocols for optimal dosing, timing, and routes of administration need to be established through further research (69,70).

Dexmedetomidine

Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist with sedative analgesic and sympatholytic effects (71). It exerts its sedative effect by acting on pre- and post-synaptic alpha-2 receptors in the locus coeruleus and its analgesic effect via alpha-2 receptors present in the spinal cord. Dexmedetomidine has a characteristic biphasic effect on the cardiovascular system, with hypotension observed at low plasma concentrations and hypertension with higher plasma concentration (for example, after an IV bolus). Bradycardia can result from the sympatholytic properties of dexmedetomidine or as a reflexive response to hypertension. Like ketamine, it does not suppress ventilatory drive, making it an attractive option for the tonsillectomy patient group (72).

A meta-analysis of 15 studies performed in 2017 demonstrated reduced analgesic usage and pain scores in the PACU for the dexmedetomidine group vs. control groups. There was wide variation in the dosing protocol between the included studies. However, the analgesic effect was seen in both the single administration of dexmedetomidine and continuous infusion. This analysis also demonstrated a reduced incidence of emergence delirium and postoperative desaturation in the dexmedetomidine groups vs. control groups (73).

Subsequent to this meta-analysis, further research continues to support dexmedetomidine use in tonsillectomy patients. Two retrospective analyses of centers that switched to a dexmedetomidine-based opioid-sparing approach demonstrated encouraging results. One center, using a dexmedetomidine (1 mcg/kg) and acetaminophen protocol, showed decreased opioid use in the PACU and eliminated the need for opioid prescriptions at discharge (74). Another center demonstrated similar analgesia with dexmedetomidine (1 mg/kg) and NSAIDs compared with morphine and acetaminophen after adopting an opioid-sparing regimen (75,76). A small RCT of 60 patients showed reduced postoperative pain and agitation with dexmedetomidine versus tramadol (77).

A retrospective cohort study published in 2021 aimed to quantify the opioid-sparing effect of dexmedetomidine and showed a reduction of 0.021 mg/kg of oral morphine equivalents for every 0.1 microgram/kg dose increase of dexmedetomidine (78).

Dexmedetomidine shows considerable promise in perioperative management for tonsillectomy patients. Its unique pharmacological profile, including analgesic and sedative effects with minimal respiratory depression, are supported by a growing body of evidence, suggesting efficacy in reducing postoperative pain. However, a large-scale randomized controlled trial is needed to definitively establish its role and support its incorporation in routine clinical practice.

Adjuvants

Dexamethasone

Dexamethasone is a potent glucocorticoid with anti-inflammatory, antiemetic, and analgesic effects and is widely used in anesthetic practice. However, possible side effects associated with dexamethasone include elevated blood glucose, immunosuppression, insomnia, and psychiatric disturbances (79).

Much literature on dexamethasone in tonsillectomy focuses on PONV, but several studies also examine its analgesic effects. A 2024 meta-analysis of RCTs by Niimi et al. found that intraoperative IV dexamethasone significantly reduced perioperative opioid use without increasing postoperative hemorrhage, recommending a minimum dose of 0.5 mg/kg (80). These findings, along with a 2011 systematic review, support dexamethasone as both PONV prophylaxis and an effective analgesic adjunct in pediatric tonsillectomy (81).

Limited literature exists on the possible adverse effects of dexamethasone in the setting of tonsillectomy, and further research is warranted. Nevertheless, its use is recommended in several guidelines, including the AAO-HNSF’s 2019 clinical practice guideline on tonsillectomy and the PROSPECT guideline (82).

Gabapentinoids

Gabapentin and pregabalin are anticonvulsant, gamma-aminobutyric acid analogs that are widely used as analgesic agents. They mediate their analgesic effect by binding to voltage-gated calcium channels in the central nervous system, inhibiting the release of excitatory neurotransmitters (83). Few studies have investigated the role of gabapentinoids in tonsillectomy (84).

A meta-analysis of nine RCTs demonstrated reduced pain and the need for postoperative analgesia in patients receiving gabapentinoids without an increased risk of adverse effects. This result is promising; however, at this time, the small study sizes and high heterogeneity between studies limit the strength of the conclusions that can be drawn. Further research is required to recommend the use of gabapentinoids in regular clinical practice (85).

Local anesthetics and regional techniques

Local anesthesia and regional techniques offer promising adjuncts in postoperative pain management following pediatric tonsillectomy. These approaches are particularly appealing as they may reduce the reliance on systemic analgesics and their associated side effects. Commonly used local anesthetics, such as lidocaine, bupivacaine, and ropivacaine, act by blocking sodium channels on nociceptive neurons, thereby interfering with pain signaling pathways. By providing targeted analgesia at the surgical site, these techniques may enhance postoperative comfort and potentially support faster recovery (86).

(I) Local anesthesia

Local infiltration involves directly injecting anesthetic into the tonsillar region, but its clinical utility remains controversial (87).

A 2023 meta-analysis by Stramiello et al., including eight RCTs, found that local infiltration significantly reduced pain scores on postoperative days 0 and 1 compared to saline controls, particularly with cold tonsillectomy techniques, with or without electrocautery (88). However, the analysis was limited by small sample sizes and heterogeneity in anesthetic agents, infiltration methods, and pain assessment tools.

In contrast, a 2019 RCT by Teunkens et al. found that children receiving local bupivacaine required more postoperative opioids and reported higher pain within the first 60 minutes compared to IV tramadol. The use of an active control enhanced clinical relevance, though reliance on IV tramadol and piritramide may limit applicability amid opioid-sparing efforts. Timing of infiltration (post-tonsillectomy) may have contributed to higher early pain scores (89).

Overall, local anesthetic infiltration in pediatric tonsillectomy remains controversial. Evidence of benefit, including opioid-sparing effects, is inconsistent. High-quality trials are needed to clarify efficacy, anesthetic choice, and timing, with use guided by patient factors and clinician expertise.

(II) Regional techniques

Regional anesthesia offers an alternative to local infiltration by targeting individual nerves, often requiring lower doses of local anesthetic, and potentially reducing systemic side effects while improving efficacy (90).

The sensory innervation of the tonsils is primarily provided by the lesser palatine nerve, a branch of the maxillary division of the trigeminal nerve, and the tonsillar branches of the glossopharyngeal nerve (91). Ultrasound-guided techniques have been developed to perform regional nerve blocks of these nerves intraoperatively and have been explored in the context of tonsillectomy-related analgesia (92). Of these, the glossopharyngeal nerve block has shown some promise in early studies. However, a recent meta-analysis by Kang et al., which included eight studies, failed to demonstrate a significant reduction in postoperative pain (93).

(III) Suprazygomatic nerve block

Suprazygomatic maxillary nerve (SZMN) block, also referred to as maxillary nerve block, pterygopalatine, or infratemporal fossa block, is a novel technique first described in 2024. It involves the injection of local anesthetic into the infratemporal-pterygopalatine fossa to provide opioid-free perioperative analgesia during pediatric adenotonsillectomy. This approach offers effective pain relief while minimizing the risks associated with opioid use in children (94).

The palatine tonsils and adenoids receive sensory innervation from multiple cranial nerve branches, including branches of those from the maxillary, glossopharyngeal, vagus, and mandibular nerves. As the SZMN block primarily targets the maxillary nerve, it provides partial analgesia, sparing the glossopharyngeal nerve, which is crucial for airway protection. Despite its benefits, the SZMN block may rarely lead to minor complications, such as localized bleeding or delayed cheek hematoma due to maxillary artery injury (95).

In a study by Lin et al. patients receiving SZMN blocks had significantly lower opioid consumption with an average morphine equivalent of 0.07 mg/kg compared (0.15 mg/kg) in the control group. Moreover, 58% of patients in the block group cohort also reported lower FLACC scores, indicating superior pain control, and no complications related to the nerve block were reported (96).

(IV) MMA

MMA is a pain management strategy that combines different medications and techniques to target multiple pain pathways, aiming to reduce opioid use and enhance postoperative pain control (97). In pediatric cardiac surgery, MMA has been shown to lower pain scores compared to traditional opioid regimens, improving recovery experiences (98). Similarly, in total joint arthroplasty, MMA is associated with better pain control and shorter hospital stays, particularly on the first postoperative day (99). In pediatric selective dorsal rhizotomy, MMA reduced opioid consumption, suggesting faster recovery potential (100).

MMA protocols can significantly decrease opioid requirements; one study reported a reduction of 0.14 morphine milligram equivalents per kilogram. Patients receiving MMA also show less need for opioids in the post-anesthesia care unit (PACU), reducing risks of opioid-related side effects. The timing of administration—pre-, intra-, or post-operative—further influences efficacy. For example, dexmedetomidine prolongs time to first analgesic need, decreases emergence agitation, and reduces opioid use in children with OSA undergoing tonsillectomy. Local anesthetics, such as peritonsillar bupivacaine, further enhance analgesia in this population. Despite these benefits, further research is needed to optimize MMA in pediatric patients. Providing written pain management guidance to patients and caregivers at discharge may also improve postoperative outcomes (101).

Non-pharmacological strategies

In addition to current pharmacological practices, non-pharmacological approaches may play a crucial supportive role in managing postoperative pain in pediatric population following tonsillectomy and adenoidectomy.

Endotracheal tube (ETT) versus reinforced laryngeal mask airway (RLMA)

In addition to pharmacological interventions, non-drug-related factors, such as the choice of air management device can significantly influence postoperative pain outcomes in pediatric adenotonsillectomy. One such factor is whether an ETT or an RLMA is used during the procedure.

A study by Doksrød et al. investigated this in a randomized trial of 134 children aged 3–16 years, assigned to either an ETT (n=62) or an RLMA (n=69) (see Figure 1). Children in the RLMA group experienced significantly lower maximum pain during the first four postoperative hours (P=0.015). Although there was a non-significant trend toward lower pain at recovery admission and 24 hours, rescue opioid use was similar. The RLMA group also spent 4.2 minutes less in the operating room (P=0.001), indicating improved procedural efficiency (102).

Figure 1 Reinforced laryngeal mask airway.

However, RLMA use carries risks, including dislocation, unintended esophageal ventilation, and limited access to the lower tonsil poles, which can complicate surgery (102). While RLMA may reduce early postoperative pain and operating room (OR) time, these benefits must be weighed against procedural risks, and airway choice should be individualized based on patient safety and surgical needs (102).

Diet modification

Diet modification plays a supportive role in managing postoperative discomfort following tonsillectomy. Offering cool, soft, and easily swallowable foods can help soothe the throat by inducing vasoconstriction, thereby reducing inflammation and providing mild to moderate analgesic effects through temporary numbness (103).

One specific dietary adjunct is honey. Owing to its anti-inflammatory and antibacterial properties, honey may promote healing by stimulating cytokine release and supporting tissue regeneration. It has been shown to accelerate wound healing in burns and may similarly aid recovery after tonsillectomy.

A study by Yeoh et al. found that honey generally reduces post-tonsillectomy pain and the need for analgesics. However, the results varied due to differences in the type of honey used and the method of administration. Honey has been shown to reduce cough frequency and severity in children with upper respiratory infections. The therapeutic potential of honey is largely attributed to its bioactive compounds, such as hydrogen peroxide, flavonoids, and polyphenols, which vary widely depending on factors including bee species, floral source, and environmental factors (104). While promising, more standardized studies are needed to establish optimal types, dosages, and delivery methods for honey in the context of post-tonsillectomy care.

Acupuncture

Acupuncture, a technique rooted in traditional Chinese medicine, involves the insertion of fine needles at specific points on the body to stimulate the body’s natural healing mechanism. It is believed to produce analgesic effects by activating neurotransmitters such as opioid peptides and serotonin, as well as by enhancing endogenous pain-inhibitory pathways (105,106).

Evidence supports the use of acupuncture as an adjunct therapy for postoperative pain management in pediatric tonsillectomy. A RCT by Gilbey et al. demonstrated that acupuncture significantly reduced the need for analgesic medications in children aged 3–12 years and also improved parental satisfaction with postoperative care (107). Furthermore, Moeen et al. showed that acupuncture at acupoints P6 (bilaterally) and CV13 was comparable to dexamethasone in reducing postoperative vomiting and also provided effective pain relief in pediatric tonsillectomy patients (108).

These findings suggest that acupuncture may offer a non-pharmacological, low-risk alternative for enhancing postoperative recovery and minimizing medication use in children, though further large-scale studies are warranted to standardize protocols and confirm efficacy.

Preoperative education

Preoperative education plays a significant role in reducing postoperative pain, with its underlying mechanism being both straightforward and compelling (109). By decreasing stress-induced activation of the hypothalamic-pituitary-adrenal (HPA) axis, preoperative education results in lower circulating cortisol levels. This reduction in cortisol, in turn, diminishes pain perception by reducing the sensitization of nociceptors (110).

Furthermore, research suggests that preoperative pain education leads to lower postoperative pain scores and reduced need for analgesics. This effect is largely attributed to the empowerment of pediatric patients through age-appropriate coping strategies and a reduction in preoperative anxiety (111). These findings highlight the importance of incorporating structured education into preoperative protocols as a non-pharmacological strategy for improving postoperative outcomes.

Alternative methods: laughter therapy, deep breathing, and storytelling

Alternative methods such as laughter therapy, deep breathing, and storytelling, are less commonly utilized in pediatric postoperative pain management but show promising potential. Laughter therapy, in particular, has demonstrated significant analgesic effects. In their review, Moll-Bertó et al. highlighted that laughter therapy can reduce postoperative pain by more than 50%, yielding results comparable to pharmacologic management (112). While laughter therapy has shown effectiveness across various clinical settings, further research is needed to confirm its efficacy specifically in the pediatric postoperative context.

These approaches, by promoting relaxation, reducing anxiety, and engaging the child’s attention, may complement conventional pain management strategies. However, standardized protocols and robust clinical trials are necessary before they can be widely integrated into postoperative care.

Surgical technique and its influence on postoperative pain

Currently, there is no universally accepted ‘gold standard’ technique for pediatric tonsillectomy. Over the years, various surgical methods have been employed, each associated with differing postoperative outcomes and complication profiles (113).

Hot dissection techniques, which use thermal energy for tissue removal and hemostasis (e.g., electrocautery or diathermy), have been consistently associated with higher patient-reported pain scores and prolonged analgesic use compared to the cold dissection techniques. Cold dissection, which avoids or minimizes thermal energy to surrounding tissues, has been shown to result in lower postoperative pain levels and faster recovery, especially in pediatric patients undergoing tonsillectomy and adenoidectomy (114).

A meta-analysis by Ahmad et al. (113) evaluated the efficacy of coblation tonsillectomy, a technique utilizing bipolar radiofrequency energy to achieve low-temperature molecular disintegration of soft tissue. Coblation allows for precise tissue removal with minimal collateral thermal damage. The analysis found that coblation was associated with reduced postoperative pain compared to traditional cold dissection. Additionally, coblation led to shorter operative times and reduced intraoperative blood loss. However, no statistically significant difference in postoperative hemorrhage rates was observed between the two methods.

Despite these promising findings, the meta-analysis demonstrated substantial heterogeneity among the included studies (τ² =0.48, χ²=32.7, df =4, P<0.00001; I²=88%). One study’s results deviated markedly from the others, prompting a secondary analysis with that study excluded. Even after exclusion, heterogeneity remained high (τ² =0.75, χ²=27.16, df =3, P<0.00001; I²=89%), underscoring the need for further large-scale, population-based studies with greater statistical power to better define the comparative efficacy, safety, and postoperative outcomes of these surgical techniques (113,115).

Local institution protocol for tonsillectomy and adenoidectomy

To provide a practical comparison with the postoperative pain management strategies discussed in this review article, Table 2 presents the local protocol for anesthesia and analgesia during pediatric tonsillectomy and adenoidectomy as followed by the Division of Pediatric Anesthesiology, Department of Anesthesiology at UT Health, McGovern Medical School, and Children’s Memorial Hermann Hospital (CMHH) in Houston, Texas.

This protocol was developed based on a comprehensive review of current evidence and the collective clinical expertise of our pediatric anesthesiology and otolaryngology teams. It has been refined over time with a strong emphasis on minimizing or avoiding narcotic use, prioritizing patient safety, comfort, and rapid recovery. In our experience, this approach has proven both effective and well-tolerated by patients.

It should be noted, however, that individual practices may vary among anesthesiologists, and the final selection of anesthetic and analgesic agents remains subject to clinical judgment and case-specific considerations.

Strengths and limitations

This review offers a comprehensive overview of current practices and emerging trends in pediatric anesthesia, drawing upon recent clinical guidelines from the AAO-HNSF to enhance both credibility and clinical relevance. It integrates detailed institutional protocols and explores alternative pharmacologic agents, such as dexmedetomidine and ketamine, which support safer pain management in pediatric populations, particularly those at risk for opioid-related complications.

However, this review also has limitations. The included studies vary widely in design, sample size, and methodology, which hinders the ability to synthesize findings regarding the effectiveness of specific analgesic regimens. Publication bias may further skew the evidence base by overrepresenting positive outcomes. Additionally, many studies focus primarily on immediate postoperative pain, with limited attention to long-term outcomes and the critical role of outpatient care.

While the efficacy of various analgesic strategies is a central theme, this review does not thoroughly address cost-effectiveness, which is crucial for real-world clinical decision-making, particularly in resource-limited settings. Emerging agents like ketamine and dexmedetomidine show promise, but further research is needed to confirm their long-term safety and efficacy in pediatric populations.

Despite ongoing uncertainty surrounding optimal pain management after tonsillectomy and adenoidectomy, we advocate for the implementation of individualized enhanced recovery after surgery (ERAS) protocols, which may help optimize outcomes. However, current adoption of ERAS protocols in pediatric otolaryngology remains limited (116).

Innovative pharmacologic approaches, such as esketamine, a non-selective, non-competitive NMDA receptor antagonist and mTORC1 activator, have demonstrated potential in reducing postoperative inflammation and pain without increasing adverse reactions (117,118). Similarly, studies have shown promise with the combination of dexmedetomidine and nalbuphine for patient-controlled intravenous analgesia (PCIA), a regimen that, while requiring inpatient monitoring, offers enhanced analgesia with fewer adverse effects and better control of stress responses (119).

Nonetheless, more robust studies are needed to refine postoperative care, especially focusing on pain that persists beyond the first 24 hours, a gap highlighted by Shih et al. (120). Finally, addressing the psychological dimension of recovery is vital. Preoperative education for both children and parents has been shown to significantly improve outcomes and reduce perioperative anxiety (121).

Conclusions

In conclusion, this review emphasizes the critical need for a multimodal approach to postoperative analgesia in the pediatric population. It aims to empower clinicians with a comprehensive understanding of both pharmacological and non-pharmacological strategies to reduce pain, minimize opioid exposure, and enhance recovery.

Given the backdrop of the ongoing opioid epidemic, there is an urgent need to explore and adopt non-opioid alternatives. This includes the integration of evidence-based institutional protocols, novel agents, and supportive non-pharmacological interventions.

Lastly, the insights presented here are not only relevant for clinical practice but also for healthcare policymakers, who play a vital role in allocating resources for research and implementation of safer, more effective pain management strategies tailored to pediatric physiology and needs.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-31/rc

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Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-31/coif). All authors received consulting fees from AMCA. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately addressed investigated and resolved.

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