The use of steroids to reduce complications after tonsillectomy: a systematic review and meta-analysis of randomized controlled studies

Tonsillectomy compared with conservative management in patients over 16 years with recurrent sore throat: the NATTINA RCT and economic evaluation

Background

The place of tonsillectomy in the management of sore throat in adults remains uncertain.

Objectives

To establish the clinical effectiveness and cost-effectiveness of tonsillectomy, compared with conservative management, for tonsillitis in adults, and to evaluate the impact of alternative sore throat patient pathways.

Design

This was a multicentre, randomised controlled trial comparing tonsillectomy with conservative management. The trial included a qualitative process evaluation and an economic evaluation.

Setting

The study took place at 27 NHS secondary care hospitals in Great Britain.

Participants

A total of 453 eligible participants with recurrent sore throats were recruited to the main trial.

Interventions

Patients were randomised on a 1 : 1 basis between tonsil dissection and conservative management (i.e. deferred surgery) using a variable block-stratified design, stratified by (1) centre and (2) severity.

Main outcome measures

The primary outcome measure was the total number of sore throat days over 24 months following randomisation. The secondary outcome measures were the number of sore throat episodes and five characteristics from Sore Throat Alert Return, describing severity of the sore throat, use of medications, time away from usual activities and the Short Form questionnaire-12 items. Additional secondary outcomes were the Tonsil Outcome Inventory-14 total and subscales and Short Form questionnaire-12 items 6 monthly. Evaluation of the impact of alternative sore throat patient pathways by observation and statistical modelling of outcomes against baseline severity, as assessed by Tonsil Outcome Inventory-14 score at recruitment. The incremental cost per sore throat day avoided, the incremental cost per quality-adjusted life-year gained based on responses to the Short Form questionnaire-12 items and the incremental net benefit based on costs and responses to a contingent valuation exercise. A qualitative process evaluation examined acceptability of trial processes and ramdomised arms.

Results

There was a median of 27 (interquartile range 12-52) sore throats over the 24-month follow-up. A smaller number of sore throats was reported in the tonsillectomy arm [median 23 (interquartile range 11-46)] than in the conservative management arm [median 30 (interquartile range 14-65)]. On an intention-to-treat basis, there were fewer sore throats in the tonsillectomy arm (incident rate ratio 0.53, 95% confidence interval 0.43 to 0.65). Sensitivity analyses confirmed this, as did the secondary outcomes. There were 52 episodes of post-operative haemorrhage reported in 231 participants undergoing tonsillectomy (22.5%). There were 47 re-admissions following tonsillectomy (20.3%), 35 relating to haemorrhage. On average, tonsillectomy was more costly and more effective in terms of both sore throat days avoided and quality-adjusted life-years gained. Tonsillectomy had a 100% probability of being considered cost-effective if the threshold for an additional quality-adjusted life year was £20,000. Tonsillectomy had a 69% probability of having a higher net benefit than conservative management. Trial processes were deemed to be acceptable. Patients who received surgery were unanimous in reporting to be happy to have received it.

Limitations

The decliners who provided data tended to have higher Tonsillectomy Outcome Inventory-14 scores than those willing to be randomised implying that patients with a higher burden of tonsillitis symptoms may have declined entry into the trial.

Conclusions

The tonsillectomy arm had fewer sore throat days over 24 months than the conservative management arm, and had a high probability of being considered cost-effective over the ranges considered. Further work should focus on when tonsillectomy should be offered. National Trial of Tonsillectomy IN Adults has assessed the effectiveness of tonsillectomy when offered for the current UK threshold of disease burden. Further research is required to define the minimum disease burden at which tonsillectomy becomes clinically effective and cost-effective.

Trial registration

This trial is registered as ISRCTN55284102.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/146/06) and is published in full in Health Technology Assessment; Vol. 27, No. 31. See the NIHR Funding and Awards website for further award information.

Effect of Oral Prednisolone on Pain after Tonsillectomy with Sutures: A Randomized Clinical Trial

Background

Tonsillectomy, one of the most common otolaryngology surgeries, often results in postoperative complications such as pain and bleeding. Currently, there is no consensus on postoperative pain management. This study aimed to determine the efficacy of oral prednisolone on postoperative pain after tonsillectomy with sutures.

Materials and Methods

This pilot, double-blind, randomized clinical trial was conducted at two tertiary care centers affiliated with Isfahan University of Medical Sciences. Patients who underwent tonsillectomy with sutures were included. Participants were randomly divided into experimental and control groups. In the experimental group, patients received oral prednisolone in addition to acetaminophen; in the control group, patients received acetaminophen and a placebo. Post-operative pain was evaluated by a visual analog scale daily for ten days.

Results

Initially, 60 patients were enrolled in the study; however, four were excluded due to non-attendance at follow-up visits. The groups were similar in terms of age and sex (both P values >0.05). In the study, postoperative pain from 1st day to the 10th day was lower in the experimental group than in the control group (P value <0.05).

Conclusion

Numerous studies have been conducted on the effect of intravenous corticosteroids on this pain. However, there is no consensus on the analgesic role of oral corticosteroids for post-tonsillectomy pain. The present study showed that oral prednisolone is effective on post-operative pain compared to a placebo.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Comparison of high-versus low-dose corticosteroid administration on post-tonsillectomy outcomes

OBJECTIVE

Intraoperative steroids have been shown to decrease post-tonsillectomy morbidity; however, optimal dosing of corticosteroids is unknown. This study evaluates the effects of high-versus low-dose dexemethasone administration (0.5 mg/kg vs. 0.1 mg/kg) on post-tonsillectomy outcomes.

STUDY DESIGN

Nonrandomized controlled study.

SETTING

Academic Medical Center.

METHODS

Pediatric patients undergoing tonsillectomy at the University of Michigan between 2017 and 2018 were identified. Uncomplicated patients between 1 and 18 years who received dexamethasone during their operation were included. Patients were categorized by high- or low-dose dexamethasone administration and outcomes assessed included revisits within 30 days for pain, vomiting/dehydration, and post-operative bleeding. The number of postoperative phone calls was also assessed.

RESULTS

A total of 1641 patients were included in the study. No significant differences in steroid group outcomes were observed regarding vomiting (1.65% vs 1.7%, p = 0.618), bleeding (1.09% vs 1.3%, p = 0.579), pain (1.64% vs 0.62%, p = 0.141), other morbidities (3.83% vs 3.57%, p = 0.493) or post-operative phone calls (10.6% vs 9.9%, p = 0.81). Post-tonsillectomy bleeding was higher for infectious etiology versus sleep disordered breathing (p = 0.005); however, no rate differences for vomiting or pain were noted. Controlling for indication, no differences in hospital return rates were seen between steroid groups.

CONCLUSIONS

No statistically significant differences in post-tonsillectomy outcome measures were observed based on administration of either high- or low-dose dexamethasone. With no observed outcome differences related to steroid dosing, we transitioned to routine use of low-dose dexamethasone for tonsillectomy and adenoidectomy.

Comparing the Effects of Pregabalin and Clonidine on Postoperative Pain in Tonsillectomy: A Randomized, Double-Blind, Prospective Clinical Trial

BACKGROUND

Tonsillectomy is one of the most common surgical procedures. This study compared the effect of Pregabalin and Clonidine on postoperative pain in adult patients undergoing elective tonsillectomy.

METHODS

This randomized, double-blind, prospective clinical trial was conducted among 92 patients aged 20 to 50. The clonidine group (C) was given 150 µg of clonidine tablet 90 minutes before surgery, and the pregabalin group (P) was given 300 mg of pregabalin tablet 90 minutes before surgery. The results were analyzed by SPSS 25, and statistical analysis consisted of chisquare, T-test, and χ2 tests, and a p-value less than 0.05 was considered significant.

RESULTS

The mean pain score and analgesic consumption scores in the pregabalin group were lower than in the clonidine group. According to the t-test, there was a significant difference between the two groups regarding pain score and analgesic consumption (p <0.05). Hemodynamic variation in both groups had no significant differences (p >0.05).

CONCLUSION

The present study showed that pregabalin reduced postoperative pain and analgesic consumption more effectively than clonidine.

Effect of intravascular dexamethasone injection after powered intracapsular tonsillectomy and adenoidectomy in children

PURPOSE

To compare postoperative pain, nausea and vomiting, and bleeding between intravascular dexamethasone injection group and control group among children undergoing powered intracapsular tonsillectomy and adenoidectomy (PITA).

MATERIALS AND METHODS

Retrospective review of medical records was performed for pediatric patients who underwent PITA from March 1, 2017, to February 28, 2021, at a tertiary referral medical center in South Korea. Postoperative pain and nausea were measured using the visual analogue scale (VAS) from the postoperative day (POD) 0 to POD 6. The number of analgesics administered and the number of vomiting episodes were recorded in the same period. The repeatedly measured parameters were statistically analyzed between the dexamethasone group and control group.

RESULTS

A total of 71 children with complete questionnaires including 44 boys and 27 girls were included, and the mean age was 7.49 ± 2.44 years. There were 33 patients in the dexamethasone group and 38 in the control group. Postoperative pain (p = 0.169) or nausea (p = 0.460) on the VAS showed no statistically significant difference between the two groups. Postoperative analgesics showed no difference between the groups (p = 0.398), and neither did postoperative vomiting (p = 0.270). In both groups, no child showed signs of postoperative bleeding.

CONCLUSIONS

This study indicates that the beneficial effects of intravascular dexamethasone administration in PITA may not be evident. This might be due to the superior outcome of the PITA technique compared to total extracapsular tonsillectomy. Therefore, otolaryngologists performing PITA may not necessarily need to administer dexamethasone in children before surgery.

How to close the gaps between evidence and practice for perioperative opioids

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.

Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era

OBJECTIVE

To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases.

REVIEW METHODS

Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings.

CONCLUSIONS

Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients.

IMPLICATIONS FOR PRACTICE

SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

The effect of postoperative steroid dosing on readmission rates following radiofrequency ablation tonsillectomy

OBJECTIVE

To examine the effect of postoperative steroid dosage on postoperative telephone calls, emergency department (ED) visits, and hemorrhage rates for two groups receiving different steroid dosing following radiofrequency ablation tonsillectomy.

STUDY DESIGN

Retrospective chart review between January 1, 2014 and January 1, 2019.

SETTING

Tertiary care pediatric hospital.

METHODS

Two postoperative steroid dosing protocols studied: 1) three postoperative doses of 0.5 mg/kg dexamethasone, or 2) three postoperative doses of 4 mg dexamethasone. Otherwise, postoperative care and pain control were similar for all patients. We hypothesized that standardized steroid dosing would achieve similar postoperative outcomes when compared to weight-based dosing with regards to patient phone calls, ED visits, readmission rates, and bleeding rates.

RESULTS

Overall, 279 patients were included (n = 100 at 4 mg, n = 179 at 0.5 mg/kg). There were no differences between groups in age, gender, race, BMI, or comorbidities (P > 0.05). Readmission and ED visit rates were 2.8% and 12.2% respectively, with no significant difference between groups (P > 0.05)). The overall hemorrhage rate was 6.3%, including those patients presenting to the ED but not requiring intervention for bleeding concerns. There was no difference in hemorrhage rates between groups (P = 0.22); the hemorrhage rate requiring operative intervention was 1.4% with no difference between groups (P = 0.27). Postoperative phone calls to physicians' office occurred in 13.3% of cases with no difference between groups (P = 0.41).

CONCLUSION

Comparable rates of readmission, ED visits, hemorrhage, and patient phone calls were seen with a standard dose of 4 mg versus 0.5 mg/kg weight-based dosing of a short course of postoperative dexamethasone following radiofrequency ablation tonsillectomy.

[German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]

Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.

Single dose of intraoperative intravenous morphine for analgesia in children undergoing tonsillectomy: Randomized, double-blind clinical trial

INTRODUCTION

Children undergoing tonsillectomy have severe pain in the postoperative period. One of the pharmacological options for analgesia is opioids, such as morphine. However, the risks of adverse effects, such as increased recovery time from anesthesia and respiratory depression, can limit its use.

OBJECTIVES

To evaluate the use of intraoperative intravenous morphine to reduce immediate postoperative pain in children undergoing tonsillectomy.

METHODS

In this double-blind randomized study, children aged 3-10 years were submitted to tonsillectomy, with or without adenoidectomy, and divided into two groups. Children in group M received 0.1 mg/kg of intravenous morphine during anesthetic induction, while those in the control group received conventional anesthesia without morphine. Postoperative pain perceptions were assessed at 30, 60, 120, 180 and 240 min after recovery from anesthesia, by the children themselves and also by their parents or guardians, using a facial pain scale.

RESULTS

A total of 57 children were included, 30 in the group with morphine and 27 in the group without morphine. According to the children themselves, the postoperative pain was less at the evaluations performed at 30 min after awakening from anesthesia (p =  0.023), while according to their parents/guardians, the pain was less intense in the evaluations performed at 30 (p =  0.002), 60 (p =  0.006) and 180 min (p =  0.007) after awakening. Moreover, postoperative analgesics were less requested by children in the morphine group. No observed side effects were associated with the use of morphine.

CONCLUSION

A single dose of intravenous morphine during anesthetic induction reduced the intensity of immediate postoperative pain in children undergoing tonsillectomy, without increasing the time of awakening from anesthesia and with lower consumption of rescue analgesics.

A review of dexamethasone as an adjunct to adenotonsillectomy in the pediatric population

Although one of the most commonly performed surgical procedures in children and frequently performed as outpatient surgery, the postoperative course following tonsillectomy may include nausea, vomiting, poor oral intake, and pain. These problems may last days into the postoperative course. Although opioids may be used to treat the pain, comorbid conditions such as obstructive sleep apnea may mandate limiting the dose and the frequency of administration. Adjunctive agents may improve the overall postoperative course of patients and limit the need for opioid analgesics. Dexamethasone is a frequently administered intraoperatively as an adjunctive agent to decrease inflammation and pain, limit the potential for postoperative nausea and vomiting, and improve the overall postoperative course. The following manuscript reviews the use of dexamethasone to improve outcomes following tonsillectomy or adenotonsillectomy, discusses the controversies regarding its potential association with perioperative bleeding, and investigates options for dosing regimens which may maintain the beneficial physiologic effects while limiting the potential for bleeding.

How Pediatric Anesthesiologists Manage Children with OSA Undergoing Tonsillectomy

OBJECTIVE

The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA).

STUDY DESIGN

Online survey.

METHOD

A sample of pediatric anesthesiologists received the survey by email.

RESULTS

110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05).

CONCLUSION

Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.