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Three Part Question

[In children following tonsillectomy] does [administration of steroids] [reduce post operative pain]

Clinical Scenario

A 17 y/o patient who is otherwise fit and well attends for removal of their tonsils. The patient has no contraindications to steroid use and you wonder whether giving steroids postoperatively will improve their pain control.

Search Strategy

Medline and Embase 1966-06 using OVID interface.
[tonsillectomy.mp] AND [steroids.mp] AND [pain.mp]LIMIT to English

Search Outcome

10 papers of which 3 were relevant and included.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Chad et al 2006 USA	Less than or equal to 18 y/o after tonsillectomy or adenotonsillectomy. 313 patients in treatment arm given single dose IV intraop corticosteroid. 313 patients in placebo/non treatment arm.	Meta-analysis of Randomised Double Blinded Controlled Trials	Pain in first post-operative day scored using visual analogue scale (VAS) 0-10	Reduction in pain on VAS. Steroid group -0.97 with P=0.01 and 95% CI -1.74 to -0.19	Studies evaluated inconsistent in regard to surgical technique, anaesthetic technique, patient populations and dexamethasone dose
Carsten et al 2000 Australia	50 consecutive patients aged 5 or over attending for tonsillectomy. 25 patients in treatment arm given 7 day course of oral prednisolone starting post op day 1 (10mg/kg for those 5-11 y/o and 0.5mg/kg in those 12 years and older)	Prospective Double-Blind Randomised Controlled Trial.	Scored from post-op day 1 to 8 on morning pain score using visual analogue scale (VAS), paracetamol use, nausea and vomiting, dietary intake, level of activity and temperature	Steroid group had less paracetamol use on days 2, 7 and 8 (P=0.3, 0.2 and 0.2 respectively). No statistical difference in all other outcomes.	Variable surgical technique and surgeon. Adults and children examined together which causes inaccuracies in pain perception.
Stewart et al 2002 Northern Ireland	200 patients aged 16 years and over. Group 1 - Piroxicam for 8 days postop Group 2 - Dexamethasone for 8 days postop Group 3 - Both drugs given for 8 days post-op	Double Blind Randomised Controlled Trial	Pain score daily for 10 days post-op using visual analogue scale (VAS)	Analgesic requirements significantly higher in Grp 1 than 2 or 3 p<0.03 for post op days 2-7. No difference in pain scores between Grp 1 and Grp 2.	Each group has significant numbers of patients lost to follow-up with no intention to treat analysis. In all groups patients given piroxicam on post-op day 1 so unable to extrapolate any differences between Grp 1 and 2 in first 24hrs post-op. Did not analyse those under 18 y/o separately to highlight any differences compared to adults.

Comment(s)

Tonsillectomy remains one of the most common procedures performed in hospitals throughout the world. Despite improvements in anaesthetic and surgical technique, post-tonsillectomy pain continues to be a significant clinical concern for particularly the young patient and their family. Pain management is often poor and such inadequacy can lead to an increased use of health services.

Clinical Bottom Line

In children aged less than 18 with with no contraindications to steroid use a single IV dose intra-operatively will reduce pain in first 24 hours. Since there is a limited cost and no significant side effects such practice is recommended. However more research is required on optimum dose. For a course of steroids 7 days post-op or more the results are not conclusive to recommend the practice currently.

References

1. Chad et al Steroids for Post-Tonsillectomy Pain Reduction: Meta-Analysis of Randomised Controlled Trials Otolaryngology-Head and Neck Surgery Feb 2006 134(2):181-186
2. Carsten et al Evaluating the Effects of Oral Prednisolone on Recovery after Tonsillectomy: A prospective, Double-Blind Randomised Trial The Laryngoscope Dec 2000 110(12):2000-2003
3. Stewart et al Dexamethasone reduces pain after tonsillectomy in adults Clinical Otolaryngology Oct 2002:27(5):321-326