Effectiveness of hyaluronic acid in post-tonsillectomy pain relief and wound healing: A prospective, double-blind, controlled clinical study

Abstract

Objectives

To find the effectiveness of hyaluronic acid in post-tonsillectomy pain relief and wound healing.

Methods

Fifty patients were included in this prospective, double-blind, controlled clinical study (20 males, 30 females mean age of 13.56 years). Hyaluronic acid was applied to one side and the other side was used as a control during tonsillectomy. Therefore, the same patient evaluated and scored the post-tonsillectomy pain, excluding individual bias.

Results

Results indicated that patients had significantly lower pain scores for hyaluronic acid treated side (p < 0.001). At the end of two weeks follow-up period, the wound in the hyaluronic acid side was almost completely healed, indicating that the healing was faster with hyaluronic acid compared to control side (p < 0.001).

Conclusion

Hyaluronic acid could be recommended as an effective treatment for the management of post-tonsillectomy pain and wound healing.

Introduction

Tonsillectomy produces an open wound, therefore, associated with significant postoperative pain which can last up to 14 to 21 days with a 2–4% risk of immediate or delayed hemorrhage [1], [3], [4], [5], [6], [7], [8]. The morbidity rate caused by postoperative pain and secondary bleeding was reported to be one in 35,000 [5], [9]. Little is known about the real cause of post-tonsillectomy pain; however the main reasons of this prolonged moderate to severe pain were described to be related with the sensitivity of tonsillar fossae to tissue damage, the disruption of mucosa, the pharyngeal muscle spasms and glossopharyngeal and/or vagal nerve fiber irritation causing inflammation [5], [6], [9].

Oral opioids such as codeine and nonsteroidal anti-inflammatory drugs are usually used to manage pain after tonsillectomy [2], [7]. It was well reported that respiratory depression, sedation and bleeding resulted from the unpredictable metabolism of opioids were one of the reasons of morphine toxicity causing morbidity and life-threading post-tonsillectomy complications [2], [5], [10]. Therefore, the use of safer opioid and non-opioid analgesics as an alternative approach to relieve the pain caused by tonsillectomy is getting more important. The American Academy of Otolaryngology—Head and Neck Surgery (AAO—HNS), for example, currently recommends the routine use of ibuprofen for pain relief after tonsillectomy [4], [5], [11].

Hyaluronic acid is a linear, hydrophilic, high molecular weight glycosaminoglycan naturally found in the joint synovial fluid and in the extracellular matrix of skin in the human body [12], [13], [14], [15]. It is naturally secreted during wound healing in proliferative phase to stimulate the migration and mitosis of fibroblasts and epithelial cells [16], [17], [18]. It was shown to reduce the levels of inflammatory mediators and, therefore, can safely be used as an anti-inflammatory agent [13], [18], [19]. Being a growth factor and having lubricant properties, hyaluronic acid is commonly used as a naturally biocompatible, biodegradable and non-immunogenic biomaterial in biological dressing formulations [19]. The positive effect of the use of hyaluronic acid in pain relief and wound healing in treatment of pressure ulcers [15], in management of osteoarthritis [12], in treatment of tendon disorders [12], in non-surgical treatment of deep wounds [20], in burns, epithelial surgical wounds and chronic wounds [18], [21] and in vocal fold wound healing in animal models [22] were reported. However, to our best knowledge there is no study investigating the effectiveness of hyaluronic acid on the treatment of tonsillectomy.

Therefore, the aim of this prospective, double-blind, controlled clinical study was to evaluate the effectiveness of hyaluronic acid on the reduction of post-tonsillectomy pain and wound healing during the first 14 postoperative days.