Epidural and intravenous fentanyl.

To the Editor: The use of local anaesthetic for tonsillectomy is not new. Combined with general anaesthesia, glossopharyngeal nerve block improves operative conditions and provides excellent postoperative analgesia. The glossopharyngeal nerve supplies most of the sensation responsible for pain transmission following tonsillectomy or uvulopalatopharyngoplasty. It can be blocked using an intraoral approach with a single point injection where the nerve lies just deep to the tonsil bed. When combined with general anaesthesia the technique decreases anaesthetic requirements and eliminates intraoperative swallowing. Adult patients report pain free periods of more than six hours postoperatively. Although children still often cry on awakening their recovery from anaesthesia appears to be much smoother. Many approaches have been described. We use the following because it does not interfere with the surgical field and it seems to have longer lasting results than peritonsillar infiltration or injection at the base of the tongue. A standard 21 gauge, 4 cm needle is attached to a Luer locked three ml syringe containing bupivacaine 0.5% with epinephrine. The distal 1.5 cm is bent to 90 ~ After induction of anaesthesia, securing the airway and providing eye protection, an assistant retracts the tonsil laterally with the suction apparatus and the tongue is retracted with a laryngoscope blade. The tip of the needle is directed laterally behind the posterior arch so that it lies deep to the tonsil bed. The point of entry is anywhere behind the posterior arch. The 90 ~ angle allows for safe contact with the retropharyngeal mucosa. The needle tip will pierce the retropharyngeal mucosa laterally and can be safely directed behind the tonsil blindly. After aspiration to avoid intravascular injection, three ml local anaesthetic are injected in an adult. For a small child the dose is one to two ml. Our surgeons and nurses have been impressed with the effectiveness of this technique in controlling postoperative pain. The time spent performing the block is more than compensated for by earlier and much smoother recovery at the end of the procedure.