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The recovery period after tonsillectomy can be quite painful. To evaluate postoperative pain, there are numerous rating scales. In addition to the age of the patient, we can use visual scales for children and numerical scales for older children and adults. The patients, doctors, parents, and nurses can make estimations of postoperative pain. Measuring pain is necessary for efficacious pain therapy two or three times per day [2, 3, 5, 10, 11].

Our aim was to compare the postoperative pain in children and adults after tonsillectomy and to evaluate the effectiveness of our pain treatment.

Children and adults admitted to our hospital for tonsillectomy were studied. The Smiley scale was used in children from 3 to 6 years. For school-aged children older than 6, as well as adults, a combined visual analogue scale (VAS) and numeric rating scale (NRS) was used. The patients recorded their pain three times per day (0=no pain, 10=maximal pain) over a 7-day period after tonsillectomy. We also monitored the techniques of anaesthesia, postoperative pain medication and postoperative complications (bleeding, emesis).

Thirty-nine children, aged 4–18 years, and 72 adults, aged 19–65 years, were enrolled. All tonsillectomies in children were performed under general anaesthesia, 3.2% of tonsillectomies in adults under local anaesthesia. If severe pain was expected postoperatively, Piritramid was given additionally during the operation. In the early postoperative period, adult patients got intravenous drugs like Piritramid. We did not use Patient-Controlled Analgesia (PCA). Children received Paracetamol suppositories at the beginning of anaesthesia and later on. While the surgery was in progress, patients were given Metamizol, Paracetamol (liquid/suppositories), and in exceptional cases only (because they cause bleeding!), Ibuprofen and Diclofenac. Additionally, the patients were given ice cream to eat and cold packs for their necks. Patients recorded their pain three times: 7 a.m., 2 p.m., and 8 p.m. (children 7 p.m.). Pain intensity in children differed from adults. From the second postoperative day to discharge from our hospital, children had significantly lower pain intensity than adults (Fig. 1, marked with *). The consumption of analgesic drugs in adults was higher then in children, and there was a difference from the first to the sixth postoperative day. On discharge from our hospital, 54.1% of children were without any pain, while 96.8% of children left the hospital with a pain score less than 3 (average of PRS from 1.19) without painkilling drugs. Only 24.3% of adults left our hospital without pain (average of PRS 2.63), 68.5% of them with a pain score less then 3. Postoperatively, 94.7% of children and 91.9% of adults had no complications.

The results of our study confirm that tonsillectomy is a very painful experience. The patients evaluated their own pain scores. The nurses and parents had underestimated the children's pain [5, 8]. Particularly in adults, the PRS was significantly higher than in children. Lavy [6] compared the scores for patients 10 years and younger with those older than 10 and saw a significant difference between the distribution of pain scores. In the younger children, he found lower pain scores than in the older ones. The mean PRS on OP Day and Day 1 were similar in our two groups, but in the adult group, the level of pain remained fairly constant until Day 5. In children, PRS peaked on the operation day and fell from 4.5 to 1.2 (adults: Peak Day 2, decrease from 4.3 to 2.6). Molony et al. [7] tried to find out on which day the pain was worst following tonsillectomy. They did not find a statistically significant day. The analgesic intake in our groups correlated with the pain intensity diagram. Our standard analgesics are Metamizol (liquid) and Paracetamol suppositories. Children given Paracetamol elixir had a higher mean Paracetamol concentration and a lower median pain score [1]. Because of hemorrhage, we do not use Ibuprofen. Harley and Dattolo [4] found a significant increase in bleeding time in the Ibuprofen group on the third postoperative day, but no changes in prothrombin time and partial thromboplastin time. Pain treatment given regularly after a tonsillectomy, starting preoperatively with Paracetamol, has significant advantages for the patients compared with a regimen in which patients receive analgesics only on demand [9].

Undertreatment of postoperative pain is a problem in clinical practice, especially in children. Our study suggests that numeric rating scales are helpful to evaluate postoperative pain and to optimize the postoperative painkilling therapy. Postoperative pain after a tonsillectomy with analgesic intake was more expensive for adults than for children. This means that after the same surgical procedure, there is more pain experienced by adults, or pain measurement in children is not so precise as that for adults.