Use of Dexamethasone to Minimize the Morbidity of Tonsillectomy

Safaa Hussain Alturaihy
Authors Emails are requested on demand or by logging in
Keywords : Dexamethasone, the Morbidity of Tonsillectomy
Medical Journal of Babylon  8:1 , 2014 doi:1812-156X-8-1
Published :2011

Abstract

Objective: To determine the effects of a single dose of dexamethasone on post-operative morbidity in patients undergoing tonsillectomy and/or adeno-tonsillectomy. Design: prospective, double-blinded, placebo-controlled clinical trail. Methods: In a period between February 2007 to January 2010 one hundred sixty patients (94 male and 66 female),aged between 4 and 42 years,undergoing tonsillectomy and/or adenoidectomy were randomized to receive a single dose of intravenous dexamethasone 0.4 mg/kg or 8 mg for adult or placebo saline single dose postoperatively and were assessed for post operative pain, nausea and vomiting, tolerance to oral intake, uvular edema, fever and the time of discharge from hospital. Result: The use of inject able dexamethasone in a dose 0f 0.4 mg per kg body weight for children or 8 mg for adult was effective in reducing post operative undesirable symptoms like pain, nausea, vomiting, edema , inadequate oral intake and fever.

Introduction

tonsillectomy is one of the most frequently performed surgical procedures in all over the word. In 1998, the rate varied from 19 per 10 000 children in Canada to 118 per 10 000 in Northern Ireland. In the United States, about 186 000 procedures are performed on an outpatient basis every year [1]. Tonsillectomy is defined as the complete removal of the tonsil from its capsule and is derived from the Latin word tonsilla, which means a stake to which boats are tied, and the Greek word ektome which means excision. Aulus Cornelius Celsus, a first century A.D. Roman writer and physician gives the earliest account of the removal of the tonsil using a finger and suggested the use of a knife in situation where the finger proved ineffective. He wrote: “…[tonsils] should be loosened by scraping around them and then torn out. When this is not possible, they should be picked up with a little hook and excised with a scalpel….” Following this description the methods for tonsillectomy eventually evolved from the use of specialized knives, wires, strings, tonsillotomes and guillotines of the past to the present day techniques[2] Despite the evolution of anesthetic and surgical techniques available, posttonsillectomy morbidity remains a significant clinical problem not only for the patient, but the family and physician as well. Pain is an important morbidity of this procedure, and the current methods to relieve pain are limited by side effects and outpatient care. Close to 40% of patients needed to visit their primary care physician or a general physician following surgery due to insufficient analgesia. A study from the Royal College of Surgeons of England demonstrated that pain was poorly controlled in 46% of patients following tonsillectomy[2]. A study in 1997 found that postoperative pain was more troublesome for the non-pediatric age group. An NHS Acute Inpatient Survey submitted by the Picker Institute in May 2003 unveiled that postoperative pain control is often inadequate with almost two-thirds of patients reporting moderate to severe pain which was not, in the opinions of 27% of patients, adequately managed. In addition to pain, nausea, vomiting and inadequate oral intake and fever are common morbidities encountered after tonsillectomy. The incidence of vomiting after tonsillectomy with or without adenoidectomy has a reported range between 40-70%. The delay in postoperative oral fluid and solid intake as a result of nausea, vomiting, or pain prolongs the time until discharge and also increases dehydration risks in early and late postoperative periods. Corticosteroids as a Method to Reduce Post - tonsillectomy Morbidity Methods for reducing pain, nausea, and vomiting after tonsillectomy are important to improve the standard of care our patients receive. During the past 35 yrs, investigators have studied the effects of systemic corticosteroids in reducing post-tonsillectomy morbidity. Unfortunately, there is no agreement regarding the routine use of corticosteroids in tonsillectomy.[2] Dexamethasone as an antiemetic: The mechanism of action of dexamethasone as an antiemetic remains unknown. Some postulate that dexamethasone exerts effects either outside the blood-brain barrier (area postrema of the brainstem) or inside the blood-brain barrier (vomiting center). In spite of the fact that the mechanism is not understood, an antiemetic benefit of corticosteroids is supported by the literature and widely accepted[3]. Dexamethasone as an antiinflammatory: In conjunction with antiemetic effects, dexamethasone may reduce inflammation at the operative site, subsequently reducing the release of inflammatory mediators into the circulation. This could also lead to less stimulation of the vomiting center mentioned previously. Dexamethasone causes inhibition of the inflammatory response blocking factors like bradykinin, prostaglandin, and leukotrienes which results in a decreased level of inflammation and reduction of the accompanying signs and symptoms including pain[3] Single injection of steroid will reduce post operative morbidity and relative low cost and safety [4]

Materials and methods

In this prospective, double-blinded,
placebo-controlled clinical trail one
hundred sixty patients, ninety-four were
male and sixty-six were female, aged 4-
42 years, who underwent tonsillectomy
with or without adenoidectomy were
randomly assigned to receive single dose
of 0.4 mg/kg or 8 mg for adult
intravenous dexamethasone
postoperatively. observing of any need
for analgesic, any oedema, fever ,
tolerating 400 ml of clear fluids milk
juce, and the discharge time all these
possible unwanted post-tonsillectomy
events was recorded. .All patients had no
contraindication for use of steroid like
hypertension or diabetes mellitus
Exclusion criteria were patients with
coagulopathy, diabetes, gastritis, peptic
ulcer, hypertension and cardiovascular
or renal disease or on therapy with
corticosteroids, oral contraceptive, antiemetics,
or aspirin. All were subjected to
preoperative evaluation for any bleeding
disorder or anemia or recent upper
respiratory tract or chest infection. 87 of
them were underwent adenoidectomy as
well,(33 were male and 34 were female)
all these patients fulfilled the routine
pre-operative protocol for
tonsillectomy/adenotonsillectomy
including history, ENT examination, and
laboratory work-up such as packed cell
volume, prothrombin time and activated
partial thromboplastin time, chest x ray,
and lateral x ray of post nasal space for
those that suspect to have adenoid
hypertrophy.
The anesthetic protocol was
standardized and did not include any
other prophylactic steroid or antiemetic
drug. All patients underwent normal orotracheal
intubation. The surgical
technique was standardized for all
patients by using the dissection method
and , Hemostasis was achieved by using
packs ,bleeders were legated using ties
with one zero silk sutures, electrocautery
was used only to treat persistently active
bleeding sites.. When indicated,
adenoids were removed using Beckmann
adenoid curette (87 patients) antibiotic
was used, Amoxicillin intravenously or
Claforan for those whom having allergy
to penicillin. Analgesia, antiemetic was
not given routinely unless the patient
needed and those are included in study
and monitored.
All patients were monitored in the
hospital for at least 24 hrs and the stay
may be prolonged depending on the
morbidity.
Each patient was monitored postoperatively
for the following events.
Pain was assessed by the need of postoperative
analgesia, i.e., when the
patient complained of pain, analgesic
was given (paracetamol 300mg every
eight hours intramuscularly) or
paracetamol syrup (Antipyrol) for
children under eight years old and
recorded.
Number of episodes of vomiting after
6 hrs following tonsillectomy were
recorded. If patient had more than two
episodes of vomiting, metoclopramide
was given and recorded.
Tolerance to intake of 400 ml of oral
fluids after 8 hrs following tonsillectomy
was recorded.
Edema as visual impression of
swelling and elongation of uvula and
soft palate was noted at 6 hrs and 24 hrs
post-operatively .
Temperature was recorded 4th hourly
for 24 hours. Temperature of > 37.5 0C
was considered as fever. Patients were
discharged after 24 hrs if good oral
intake was achieved and when they were free from complications like bleeding,
fever, pain, dehydration etc. Those
patients who re-attend with secondary
post-tonsillectomy and or postadenoidectomy
hemorrhage, were
admitted.
All patients had a regular follow-up
visit with on 7th, 14 th post-operative
day and information like fever, bleeding,
vomiting and oral intake were collected
during these visits healing time of the
tonsil beds with complete removal of
slough and solid food intake with any
accompanied symptoms like ear pain,
dysphagia was noted at follow-up visit.
Statistical analysis:
Test of difference between two
proportions are studied to determine
significant difference between the
groups.





Results

One hundred sixty patients between 4-42 years of age were randomized to receive dexamethasone and were divided into two groups (A) and (B), (A) is of 84 patients that receive dexamethasone and (B) is of 76 patients that receive placebo (5 ml ) of normal saline ,no adverse affect of this drugs were reported in this study .. Dexamethasone was selected because a long half-life of 36 to 48 hours with glucocorticoid activity(4).A single dose lacks side effect like gastritis, adrenal depression, etc., and also has a low cost. There was no significant difference in gender between two groups male to female ratio was 1:0.66 in the study group and1:0.73in the control group. On the day of operation ,only 12 patients out of 84 need analgesic, where as 36 of 76 in the placebo, thethis implies a statistically significant relative decrease in post operative pain on the day of operation for those patient who received dexamethasone. (p>0.0001) Fifty patients in the placebo group had more than two episodes of vomiting after six hrs post-operatively compared to only four patients in the trial group,this implies a significant decrease in postoperative nausea and vomiting (PONV). (p<0.0001). All patients receiving dexamethasone were able to tolerate 400 cc of oral fluids at 8 hrs following surgery where as non of the patients receiving the placebo could tolerate oral fluids at 8 hrs postoperatively. Thus, dexamethasone significantly improves oral intake in post-tonsillectomy patients (P<0.001). The incidence of edema was significantly less in the study group (16 Vs 58) so the p<0.0001 at the end of 24 hrs after surgery. On the day of surgery, fever was recorded only in 4 patients from the study group compared to 16 patients in control group( P<0.01). All patients receiving dexamethasone were fit for discharge after 24 hrs postoperatively ,but sixteen patients in the placebo group had to prolong their hospital stay due to morbidities like pain and dysphagia (p<0.0001).Thus dexamethasone significantly promotes early discharge of post-tonsillectomy patients. Non of patients from the study group got re-admission to hospital (p<0001). A Sixty-six patients of study group completed healing with normal tonsil bed on seventh post-operative day(POD) whereas only sixty-six patients from the control group completed healing after the fourteenth POD.Since none in the control group completed healing on seventh POD,(P>0.05).

Discussions

Tissue injury induced acute inflammation ,nerve irritation and spasm of exposed pharyngeal muscle is known to play a role in the genesis of posttonsillectomy pain [4]. By inhibiting phospholipase enzyme, corticosteroid block both the cyclooxygenase and lipo-oxygenase pathway and thus prostaglandin production, thereby, leading to pain relief [4]. Corticosteroids reduce the inflammation by inhibiting the early processes of the inflammatory process of the inflammatory response which include edema, fibrin deposion, capillary dilatation, migration of lymphocytes and phagocytic activity[5]. Corticosteroid reduce edema, whether the cause of inflammation is infection, trauma or allergy[6] and are used extensively in otolaryngology in managing airway compromise as a result of epiglottitis laryngeal trauma laryngotracheobronchitis,allergic laryngeal edema,subglottic stenosis and adenotonsillar enlargement secondary to acute infection[7]. When given intravenously before surgery,dexamethasone has been effective in educing postoperative edema ,pain, and trismus in patients who have gone for impacted third molar[8].Given this accumulated information, it seems that dexamethasone given before tonsillectomy would improve the patient s postoperative pain. Oropharyngeal pain and irritation of gastric mucosa by swallowed blood are the main contributors for high incidence of PONV following tonsillectomy, this was the same as Haris Al (9).Steroid exert anti-emetic activity via prostaglandin,release of endorphins and tryptophan depletion [9] Multiple studies have shown benefits with corticosteroids alone or as adjuvant for chemotherapy induced vomiting, gynocological surgeries, thyroidectomy,andtonsillectomy induced vomiting.[10-14]. Henzi et al did metanalysis of 17 trails involving use of dexamethasone for prevention of PONV in surgical patients[15]. Local infiltration of steroids and an oral four days course of steroids have shown promising result in tonsillectomy patients [16,17].However the literature regarding the use intravenous corticosteroids for tonsillectomy is conflicting ,most of the studies have either lacked the control group or are not standardized for anesthetic procedure as well as surgical technique. There are controversies about the type and dose of corticosteroid ,whether to use single or multiple doses and whether to use alone or adjuvant to other drug [18]. Mc Keam et al did a double blind randomized controlled trail for intravenous steroid for adult tonsillectomy and concluded that a single dose of 10 mg of dexamethasone given intravenously at induction of anesthesia for adult tonsillectomy significantly decrease the pain scores for the day of operation and the mean pain score for the week post-operatively was significantly reduced in these patients[19]. In this study, there was no difference noted in the time of first ingestion of food and drink same as Ajmee et al[18], also this finding was the same as Anila [20] In our study there was a significantly better quality of oral intake with dexamethasone, perhaps due to less pain and inflammation, and all patients can tolerate 400 ml of oral fluids at eight hours following surgery and none of the saline group was able to tolerate oral fluid eight hours following surgery. In meta-analysis Steward et al showed that children received dexamethasone were more likely to advance to soft or solid diet on posttonsillectomy day one[21], While our study did not show that dexamethasone can be used to control post-tonsillectomy fever this finding agree with Anila et al in study of ninety patients for effects of dexamethasone on post tonsillectomy morbidities [20]. All patients who received dexamethasone were able to discharge after 24 hours, this perhaps due to decrease in overall post tonsillectomy morbidity this agree with al Ajmee et al and Stewart et al [18,21].

Conclusions

From our study we can conclude that the routine use of dexamethasone seems reasonable in minimizing posttonsillectomy morbidity ,dexamethasone is considered safe and there were no adverse effects associated with single dose of dexamethasone but if this is to be adopted as a routine in minimizing the post tonsillectomy morbidity in clinical practice further studies regarding the effect of intravenous dexamethasone are needed Our results showed that the use of dexamethasone 0.4 mg/kg in patients undergoing tonsillectomy and/or adenoidectomy significantly decreases the incidence of post operative, pain nausea, vomiting, and edema of uvula and soft palate. It also improves oral intake, shortens duration of hospital stay, reduces incidence of readmission and promotes early healing of tonsil bed significantly. Moreover, this single dose of dexamethasone is a safe and inexpensive method for reducing morbidity in tonsillectomy. But in this study, dexamethasone did not appreciably influence the fever in posttonsillectomy patients Even though a bigger sample size can increase the statistical power of the study.

References

1 Christoph Czarnetzki et al
Dexamethasone and Risk of Nausea and
Vomiting and Postoperative Bleeding
After Tonsillectomy in Children,A
randomized trail
JAMA. 2008;300(22):2621-2630
2Rayan W.,Ritley ,steroid and antibiotic
in tonsillectomy,Grand round
presentation,UTMB,Department of
otolaryngology,April 2008,
3 DL Steward et al,Do steroid reduce
morbidity of steroid?,meta-analysisof
randomized trail,laryngoscope,2001
111;1712-1718
4 Niels mygind and jens
thomson,corticosteroid in
otolaryngology, scott-brown s
otolaryngology,head and neck
surgery,7th edition,2007,chapter 34,418-
428
5 Goodman LS, Gillman A. Editors. The
pharmacological basis of therapeutics.
5th ed. New York: MacMillan
Publishing Co.; 1975: 148
6 Melby JC. Systemic corticosteroid
therapy: pharmacology and
endocrinologic considerations. Ann
Intern Med 1974; 81:505-512
7 Hawkins DB, Crockett DM.
Corticosteroid in airway management.
Otolaryngol Head Neck Surg 1983;
91:593-596.
8 Hoffman CG. Use of methyl
prednisolone sodium succinate to reduce
post-operative edema after removal of
impacted third molars. J Oral Surg 1977;
35:198-199.
9 Harris AL. Cytotoxic-therapy-induced
vomiting is mediated via encephalin
pathways. Lancet 1982; 1:714-716.
10 Pappas LS et al, The effect of
preoperative dexamethasone on the immediate and delayed postoperative
morbidity in children undergoing
adenotonsillectomy. Anesth Analg 1998;
87:
57-61.
11. Marie TA,et al. The effect of
dexamethasone on postoperative
vomiting after tonsillectomy. Anesth
Analg 2001; 92: 636-639
12 Jhi JW,et al Shung. The use of
dexamethasone for preventing
postoperative nausea and vomiting in
females undergoing thyroidectomy: a
dose ranging study. Anesth Analg 2000;
91: 1404-1407
13 Wang JJ,et al. The prophylactic effect
of dexamethasone on postoperative
nausea and vomiting in women
undergoing thyroidectomy: a
comparison of droperidol with saline.
Anesth Analg 1999; 89: 200-203.
14 Kang L, Chi CH, Yuan YC. The
effective dose of dexamethasone for
antiemesis after major gynecological
surgery. Anesth Analg 1999; 89: 1316-
1318.
15 Henzi I, Walder B, Tramer MR.
Dexamethasone for the prevention of
post-operative nausea and vomiting: A
quantitative and systematic review.
Anesth Analg 2000; 90:186-194
16 Rundle FW. Post-tonsillectomy
morbidity: A clinical trial of a local
penicillin steroid – anesthetic mixture.
Ann Otol
Rhinol Laryngol 1967; 76:10601066
17 Anderson HA, Rice BJ, Cantrell RW.
Effects of injected deposteroid on post
tonsillectomy morbidity: A double
18Monther Ali Alajmi et al Steroids for
Reducing Post-Tonsillectomy Morbidity
Kuwait Medical Journal 2008, 40 (3):
211-215
19McKean S, Kochilas X, Kelleher R,
Dockery M. Use of intravenous steroids
at induction of anesthesia for adult
tonsillectomy to reduce postoperativea
nausea and vomiting and pain. Clin
Otolaryngol 2006; 31:36-40
20Anila D. Malde et al,effect of
dexamethasone on post tonsillectomy
morbidities, indian journal of
anaesthesia, 2005. 2005; 49 (3) : 202 -
207
21Steward DL, Welge JA, Myer CM.
Do steroids reduce morbidity of
tonsillectomy? Meta-analysis of
randomized trials. Laryngoscope 2001;
111:1712-1718


The complete article is available as a PDF File that is freely accessible. The fully formatted HTML version can be viewed as HTML Page.

Medical Journal of Babylon

volume 8 : 1

Share |

Viewing Options

Abstract
Download Abstract File
8_1_85.pdf

Related literature

Cited By
Google Blog Search
Other Articles by authors

Related articles/pages

On Google
On Google Scholar
On UOBabylon Rep

User Interaction

1206  Users accessed this article in 1 year past
Last Access was at
14/11/2018 03:48:09