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September 20, 2014

Steroids Helpful After Tonsillectomy?

Pain is perhaps the most common dreaded fear patients have when considering tonsillectomy surgery.  After pain, bleeding is perhaps the 2nd greatest concern patients have. With both these issues, steroids play a key role by helping with one at the expense of the other.

In the 2011 Clinical Practice Guideline: Tonsillectomy in Children, the authors strongly recommend giving a single large dose of steroids to help with not just pain, but also nausea and vomiting after surgery. It is not just in kids... Steroids also help with pain control in adults.

So if steroids are so helpful, why is only a single dose recommended? Why not give more?

Although there is little evidence that a single dose of steroids significantly increases the risk of bleeding in the post-operative period, there is concern that the same may not hold true if too much is administered. As such, routinely giving more than one dose of steroids is NOT recommended.

However, even with a single dose of steroids, there is still persistent concern for bleeding in children as a recent 2014 study found. As such, the (?nominal) bleeding risks need to be weighed against the definite positive benefit patients have in terms of reduced pain, nausea, and vomiting.


Given this background, the vast majority of ENTs who routinely perform tonsillectomy do give a single dose of intra-operative steroids given it is felt that the benefit does far outweigh the risks.

Another steroid dose "may" be given orally if pain suddenly increases 5-7 days after surgery, but certainly not something that is recommended to be done routinely and best to be avoided if possible.

References:
Clinical Practice Guideline Tonsillectomy in Children. Otolaryngol Head Neck Surg January 2011 vol. 144 no. 1 suppl S1-S30

Impact of Systemic Steroids on Posttonsillectomy Bleeding: Analysis of 61 430 Patients Using a National Inpatient Database in Japan. JAMA Otolaryngol Head Neck Surg. 2014 Sep 18. doi: 10.1001/jamaoto.2014.2009. [Epub ahead of print]

Effects of oral prednisolone on recovery after tonsillectomy. Laryngoscope DOI: 10.1002/lary.24958

Perioperative dexamethasone administration and risk of bleeding following tonsillectomy in children: a randomized controlled trial. JAMA. 2012 Sep 26;308(12):1221-6.

Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial. JAMA. 2008 Dec 10;300(22):2621-30. doi: 10.1001/jama.2008.794.

Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD003997. doi: 10.1002/14651858.CD003997.pub2.



Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

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