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Postoperative Oral Dexamethasone and Pediatric Tonsillectomy Morbidity: A Randomized Clinical Trial
Amber D Shaffer1, Mahmoud Omar2,3, Raymond C Maguire1
1Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
Insights
Postoperative oral dexamethasone may modestly reduce pain after pediatric adenotonsillectomy. This steroid use also significantly decreased opioid prescriptions and emergency department visits for pain without increasing complications.
Area of Science:
- Otolaryngology
- Pediatric Surgery
- Pharmacology
Background:
- Tonsillectomy is a highly painful procedure for children.
- The effectiveness of postoperative oral steroids in managing pediatric tonsillectomy pain and related complications is not well-established.
Purpose of the Study:
- To evaluate the efficacy of postoperative oral dexamethasone in reducing pain and morbidity following pediatric adenotonsillectomy.
Main Methods:
- A quadruple-blinded, randomized clinical trial involving pediatric patients (3-17 years) undergoing adenotonsillectomy.
- Participants received either oral dexamethasone or a placebo on postoperative days 2, 4, and 6.
- Pain scores, adverse events, and healthcare utilization were monitored for up to 9 weeks.
Main Results:
- The dexamethasone group showed a trend towards lower mean pain scores (0.72 points less) on days 2-8, though not statistically definitive.
- Significant reductions were observed in opioid prescriptions (OR 0.23) and emergency department visits for pain (OR 0.12) in the dexamethasone group.
- No significant differences were found in readmissions, calls to nurses, post-tonsillectomy hemorrhage, or return to a normal diet.
Conclusions:
- Postoperative oral dexamethasone appears to be a safe analgesic adjunct for pediatric adenotonsillectomy.
- It is associated with a modest reduction in pain and a significant decrease in opioid use and pain-related ED visits.
- Further research with enhanced precision is needed to confirm pain reduction findings.
Importance:
Tonsillectomy is among the most painful otolaryngologic procedures. It is unclear whether a postoperative course of oral steroids reduces pediatric tonsillectomy pain and morbidity.
Objective:
To determine whether a postoperative course of oral dexamethasone reduces postadenotonsillectomy pain in children.
Design, Setting, And Participants:
This was a parallel-design quadruple-blinded randomized clinical trial conducted at a single tertiary academic center that enrolled pediatric patients (3-17 years of age) undergoing adenotonsillectomy from August 2021 to May 2023, with 14 days of follow-up for pain and 5 to 9 weeks for adverse events. Data were analyzed from October 2023 to May 2026.
Intervention:
Oral dexamethasone (0.5 mg/kg; maximum dose, 20 mg) or placebo on postoperative days 2, 4, and 6.
Main Outcome And Measure:
Mean (SD) pain score before medication administered during days 2 to 8 postoperatively.
Results:
Of 763 children screened, 209 participants (median [IQR] age, 7.1 [5.8] years; 99 females [47.4%] and 110 males [52.6%]) were included (104 to the steroid arm and 105 to placebo) in analyses of adverse events and health care utilization. Of these, 131 (61 steroid arm and 70 placebo) completed pain diaries and were included in primary outcome (pain) analysis. Mean (SD) pain before acetaminophen or ibuprofen on days 2 to 8 was 0.72 (95% CI, 0-1.44) points lower in the dexamethasone group (4.12 [2.00]) than placebo (4.84 [2.15]), but wide 95% CIs and differences in pain prior to taking the study medication prevented making definitive conclusions. The dexamethasone group had less pre- and postanalgesic pain on postoperative days 12 and 13 (mean difference, 0.96-2.37 points) and a considerable decrease in odds of receiving an opioid prescription (odds ratio [OR], 0.23; 95% CI, 0.06-0.84) or having an emergency department visit for pain (OR, 0.12; 95% CI, 0.003-0.91). However, the precision of these estimates limits interpretability. Differences in readmissions, nursing telephone calls, posttonsillectomy hemorrhage, and return to normal diet between groups were small and clinically meaningless.
Conclusions And Relevance:
In this randomized clinical trial, postoperative oral dexamethasone was associated with a modest reduction in pain after pediatric adenotonsillectomy, a considerable reduction in opioid prescriptions, and no increase in complications, supporting its use as an analgesic adjunct.
Trial Registration:
ClinicalTrials.gov Identifier: NCT04879823.
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