Dexamethasone Effective in Relieving Postoperative Pain After Tonsillectomy

Newswise — With 600,000 tonsillectomies performed each year on children and adults, post-operative pain continues to be a major concern despite improvements in anesthetic and surgical technique. Previous meta-analyses have demonstrated that steroids can significantly reduce postoperative vomiting and hasten early return to diet. However, the lack of reporting, insufficient data, or varied outcome measures, has resulted in post-tonsillectomy pain to not be included as a factor endpoint. However, new research has been conducted shedding insight into the effect of steroids on post- operative pain.

A systematic review of the published literature using established meta-analysis techniques, with a predetermined protocol, has been performed to formulate an objective recommendation regarding the efficacy of routine use of a single, intraoperative, intravenous dose of corticosteroid on post-tonsillectomy pain, The researchers, using their clinical experience and information retrieved from recently published randomized studies, speculate that a single intravenous dose of dexamethasone reduces post-tonsillectomy pain. Their goals were to determine whether a meta-analysis of randomized trials would statistically support this hypothesis and whether this support would have clinical relevance.

The authors of "Steroids for Post-tonsillectomy Pain Reduction: Meta-analysis of RCTs," are Chad E. Afman MD, Jeffrey A. Welge PhD, and David L. Steward MD, all from the Department of Otolaryngology—Head and Neck Surgery, University of Cincinnati, Cincinnati, OH. Their findings are to be presented at the 109th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 25-28, 2005, at the Los Angeles Convention Center, Los Angeles, CA.

Methodology: The test hypothesis was that a single, intraoperative, intravenous dose of corticosteroid is no better than placebo or nontreatment in reducing pain following pediatric tonsillectomy or adenotonsillectomy. The study primary end point was pain in the first postoperative day. This was conducted in randomized, double-blinded, controlled trials that used a pain scale to compare pain during the 24 hours after tonsillectomy or adenotonsillectomy in pediatric patients (age ≤18 years) either given a single dose of intravenous, intraoperative corticosteroid or placebo/non-treatment.

The search strategy so defined yielded 187 candidate titles and abstracts for review. These titles and abstracts were reviewed for possible inclusion in the meta-analysis. Foreign language publications were translated and evaluated.

Studies were excluded if they used therapy other than single-dose, intravenous, intraoperative corticosteroid, were not randomized, or were not placebo or non-treatment controlled. Studies not collecting or reporting data on the primary outcome of pain or not measuring pain on a pain scale (i.e., analgesic use only or dichotomous data only) were also excluded.

Results: Eight randomized trials, involving 626 patients, were included in the meta-analysis of post-tonsillectomy pain. . The doses of dexamethasone in the included studies ranged from 0.4 to 1.0 mg/kg with maximum doses anywhere from 8 to 50 mg. Studies were published between 1993 and 2005 in the otolaryngology and anesthesia literature.

Postoperative pain was evaluated by analyzing the Visual Analogue Scores (VAS) during the first 24 hours after tonsillectomy for both controls and those treated with steroid. A significant reduction of pain as measured by mean VAS (scale 0-10) on post operative day one favored the steroid group with a difference of -0.97, with P = 0.01 and 95 percent CI of -1.74 to -0.19. This translates to a reduction of pain by a factor of one on a 10-point scale for patients treated with steroid compared to controls. Statistically this was a significant reduction in post-tonsillectomy pain.

Conclusions: Previous meta-analyses have demonstrated that steroids can significantly reduce postoperative emesis and hasten early return to diet. The authors propose that the results of this meta-analysis suggest that a single, intraoperative dose of dexamethasone also reduces post-tonsillectomy pain on postoperative day one, by a factor of about one on a ten-point pain scale.

This additional benefit of reducing post-tonsillectomy pain in the first 24 hours, along with the low cost of dexamethasone and it lack of serious side effects leads us to recommend a single-dose of intravenous dexamethasone during routine tonsillectomy or adenotonsillectomy for an otherwise healthy child. Further study is warranted to determine optimum dosing. In addition, further study is suggested to determine possible benefit in the adult patient having tonsillectomy.