Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2013) 14, 113117

Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences
www.ejentas.com

ORIGINAL ARTICLE

Preoperative administration of dexamethasone reduces

post-tonsillectomy morbidities in adults
a,* b
Ahmed Hafez Khafagy , Sameh M. Osman

a
Department of Otolaryngology Head & Neck Surgery, Ain Shams University Hospital, 11566 Cairo, Egypt
b
Department of Anaesthesiology, Ain Shams University Hospital, Egypt

Received 10 February 2013; accepted 4 May 2013

Available online 28 May 2013

KEYWORDS Abstract Aim: To investigate the efcacy of dexamethasone on the quality of life in adult tonsil-
Dexamethasone; lectomy patients in terms of postoperative nausea, vomiting, and pain.
Tonsillectomy; Materials and methods: In this study, 106 adult patients of control and study groups were
Postoperative nausea and injected with 2 ml intravenous normal saline and dexamethasone in a dose of 0.3 mg/kg (maximal
vomiting (PONV); dose 8 mg), respectively, during the induction of anesthesia, prior to cold dissection tonsillectomy.
Anesthesia; Post-operative pain scores, incidences of nausea and vomiting, and the duration of oral intake were
Postoperative morbidity compared in both groups.
Results: The overall post-operative incidences of nausea and vomiting and pain scores of 74
patients were signicantly less in the study group (n = 43) as compared to the control group
(n = 31). The study group could intake liquid and solid foods earlier than patients of the control
group.
Conclusion: Pre-operative administration of dexamethasone signicantly reduces post-tonsillec-
tomy morbidities such as nausea, vomiting, and pain with early resumption of oral intake.
2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and
Allied Sciences.

1. Introduction

Tonsillectomy is an age old surgical technique commonly per-

formed by surgeons worldwide in response to treatment of
* Corresponding author. Tel.: +20 965 97215597; fax: +20 965 recurrent chronic tonsillitis, obstructive sleep apnea, and re-
25359037. lated conditions, tonsillar hypertrophy, snoring, or peritonsil-
E-mail addresses: ahmedkhafagy@yahoo.com, ahmed_khafagy67@ lar abscess.1 The cold dissection method of tonsillectomy is
yahoo.co.uk (A.H. Khafagy).
highly preferred by surgeons as it allows a very thorough, care-
Peer review under responsibility of Egyptian Society of Ear, Nose,
ful, and effective removal of all lymphoid tissues. However, as
Throat and Allied Sciences.
the surgery causes mechanical tissue damage, the prevalence of
associated complications and postoperative morbidities such
as pain, emetic episodes, nauseatic feelings, dehydration, and
Production and hosting by Elsevier poor oral intake are direct responses to this event.2,3 Incidences

2090-0740 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2013.05.001
114 A.H. Khafagy, S.M. Osman

of postoperative nausea and vomiting (PONV) are associated followed by surgeons for both groups prior to the surgery. Pa-
with severe pain causing local inammation, venous hyperten- tients of the study group received the corticosteroid dexameth-
sion, hemorrhage, and pulmonary aspiration.4 Despite the asone (Decadron MSD) intravenously in a single dose of
availability of various analgesic and antiemetic regimens 0.3 mg/kg, maximal dose 8 mg, 15 min prior to start of the sur-
post-tonsillectomy, patient surveys have indicated that moder- gery, during the induction of general anesthesia while the con-
ate-to-severe postoperative pain is still poorly managed.5 trol group did not receive any steroids. Patients of the control
Results of many published clinical studies provide evi- group were injected with the similar amount, i.e., 2 ml of nor-
dences regarding the benecial effects of steroids with regard mal saline solution during anesthetic induction. The cold dis-
to decreasing episodes of nausea, vomiting and pain, following section technique was followed for the tonsillectomy and
tonsillectomy.6,7 Of all steroids, glucocorticoids have the most general postoperative measures were standardized for both
powerful anti-inammatory characteristics. Administration of groups.
corticosteroid regimens has been proved to be safe and effec- All patients were discharged after 24 h stay in hospital,
tive in managing mild-to-moderate postoperative pain man- post-tonsillectomy. Patients were prescribed with the following
agement after tonsillectomy with no contraindications to oral medication (analgesics and antiemetics), for relief from
their use.8,9 Dexamethasone is a potential glucocorticoid drug pain and vomiting, during and after their hospital stay, till se-
that acts as an anti-inammatory and immunosuppressive ven days duration, post-surgery.
agent. The prolonged analgesic and antiemetic effects of dexa-
methasone help to improve the quality of life in adult patients  Paracetamol tablets (1 g every 6 h)
post-tonsillectomy by reducing the tissue damage and local  Diclofenac dispersible (50 mg every 8 h)
inammation by blocking the inammatory mediators, prosta-  Dihydrocodeine (30 mg every 6 h interval/day)
glandin antagonism, release of endorphins, and tryptophan
depletion. Many previously published studies have further Patients were asked to ll in a written questionnaire, where
conrmed that single, low dose intravenous administration they had to note the time of their rst intake of solid and liquid
of dexamethasone, prior to tonsillectomy, during the induction food after surgery along with incidences of nausea, vomiting,
of anesthesia, considerably reduces postoperative morbidities and severity of pain each day, from the day of surgery till
such as pain, nausea, and vomiting, and improves quality of the next seven days. To determine the postoperative extent
oral food intake.1013 of pain in patients, the visual analogue scale (VAS) of pain
This study was conducted in an aim to investigate the ef- scores was used where 0 represented no pain and 10 repre-
cacy of a single dose of dexamethasone administered intrave- sented severe pain. Patients were asked to label a score of
nously prior to tonsillectomy, on postoperative nausea, 04 for mild pain, 57 for moderate pain, and 810 for severe
vomiting, and pain on the quality of oral intake in a group pain on the VAS. To assess the postoperative occurrences of
of adult patients undergoing cold dissection tonsillectomy, nausea and vomiting (PONV) or incidences of emesis, patients
using a standardized anesthetic and surgical procedure. Re- were asked to note the number of emetic episodes per day.
sults obtained from the study and control groups were com- Three or less episodes per day were considered as mild PONV,
pared to determine if the preoperative administration of four or more episodes per day were labeled as moderate
dexamethasone is benecial in reducing postoperative PONV, and more than eight episodes per day were marked
morbidities. as severe PONV. Patients were also asked to note the postop-
erative duration of rst liquid and solid oral food intake as the
2. Materials and methods delay in postoperative oral uid and solid intake as a result of
nausea, vomiting, or pain prolongs the healing time and in-
The current randomized controlled clinical trial was con- creases dehydration risks in early and late postoperative peri-
ducted at the Department of Otorhinolaryngology, Ain- ods. Based on the comparison of these data, the difference in
Shams University Hospital, Egypt, during 20062011. The healing times between both groups could be determined. These
selection criteria for this study included adult patients of details were collected from patients when they came to the hos-
age 1565 years, weighing 40100 kg, ASA (American Soci- pital on the seventh day for their follow-up check-up.
ety of Anesthesiologists) physical status I and II, undergoing
elective tonsillectomy. Patients with suspected malignancy 3. Statistical methods
and those with contraindication in using non-steroidal
anti-inammatory drugs were excluded from the study. Data analysis was performed using the SPSS (Statistical
Thus, after obtaining approval from the hospitals ethics Package for the Social Sciences) software, version 17.0. The
committee and informed consent from patients, a total of data were expressed as mean (standard deviation SD) for
106 adult patients (65 males and 41 females) were enrolled normally distributed data and median (inter-quartile range
for the study. IQR) for non-normally distributed data. Mean and standard
For standardization of the study outcome, all surgeries deviation were calculated for age and weight of these 74 pa-
were conducted by the same surgeon and anesthetic procedure tients. The KolmogorovSmirnov test was used to test normal-
was the same for all patients and was performed by one anes- ity of the distribution. Paired t-test and Wilcoxon Signed rank
thetist. Patients were randomly, using sealed envelops, allo- test were applied to examine statistically signicant differences
cated into study and control groups (53 patients in each between the two groups for severity of pain and incidences of
group), i.e., patients were randomized to receive either dexa- PONV on the day of operation and till seven days post-oper-
methasone (study group) or an equivalent volume of normal ation. P values less than 0.05 were considered to be statistically
saline (control group). General anesthetic procedure was signicant.
Preoperative administration of dexamethasone reduces post-tonsillectomy morbidities in adults 115

Table 1 Demographic data of adult patients undergoing tonsillectomy.

Details Control group (n = 31) Study group (n = 43)
Gender Male Female Male Female
Age range (mean), in years 1564 (31) 1560 (28) 1665 (34) 1559 (29)
Weight range (mean), in kgs 40100 (58) 4083 (54) 4098 (56) 4185 (50)

Table 2 Incidences of post-operative nausea and vomiting (PONV).

Operation day 1st POD 2nd POD 3rd POD 4th POD 5th POD 6th POD 7th POD
Control group (n = 31) 24 6 8 3 1 3 2 1
Study group (n = 43) 13 7 5 5 6 9 6 4
P value 0.003 2.80 0.93 1.30 1.20 7.3 7.1 2.03
POD: Postoperative day.

Table 3 Post-tonsillectomy mean of pain scores.

Operation 1st 2nd 3rd 4th 5th 6th 7th Overall mean of
day POD POD POD POD POD POD POD pain scores
Control group 7.5 4.3 6.1 6.4 6.7 7.0 5.9 6.2 6.3
(n = 31)
Study group 5.1 3.7 5.2 5.6 4.9 5.5 4.3 4.6 4.9
(n = 43)
Relative change 32.0 14.0 14.7 12.5 26.8 21.4 27.1 25.8 22.2
(in%)
P value 0.008 0.516 0.091 0.05 0.03 0.009 0.02 0.01 0.002
POD: Postoperative day.

Table 4 Post-tonsillectomy duration of rst oral food intake.

Duration of rst liquid oral food intake Duration of rst solid oral food intake
after operation (in hrs) after operation (in hrs)
Control group 2.3 6.0
(n = 31)
Study group 1.8 4.8
(n = 43)
P value 0.218 0.05

4. Results while in the study group there were 28 males (age group = 16
65 yrs, mean age = 34 years; weight range = 4098 kg, mean
On the seventh day of follow-up, complete data were obtained weight = 56 kg) and 15 females (age group = 1559 years,
in the form of lled questionnaires only from 74 patients mean age = 29 years; weight range = 4185 kg, mean
(70%) out of the 106 operated patients. These data were sub- weight = 50 kg) (Table 1).
sequently used to evaluate and compile the results. Of these 74 The overall incidence of PONV in the study group showed
patients, 31 patients belonged to the control group and 43 pa- a signicant decrease (p = 0.03) of around 65% as compared
tients belonged to the study group. All these patients under- to the control group, when data obtained on the operation
went cold dissection tonsillectomy with single dose day and on the seventh day post-operation were compared
preoperative dexamethasone given in the study group and no for both groups (Table 2). The postoperative pain score had
dexamethasone in the control group. The 74 adult patients in- also signicantly decreased (p = 0.018) by 26% in the study
cluded 48 males and 26 females. There were 20 males (age group as compared to the control group on the same day of
group = 1564 years, mean age = 31 years; weight operation. Further, when the overall pain score after seven
range = 40100 kg, mean weight = 58 kg) and 11 females days of operation was measured for both groups, it showed
(age group = 1560 years, mean age = 28 years; weight a signicant decrease by 14.6% (p = 0.003) in the study group
range = 4083 kg, mean weight = 54 kg) in the control group, as compared to the control group (Table 3). When the dura-
116 A.H. Khafagy, S.M. Osman

tion of rst liquid and solid food intake, post-tonsillectomy, adults, but dizziness was increased due to the addition of pre-
was compared in both groups, results showed that patients gabalin. Buland et al.23 documented that single dose perioper-
of the study group could take liquid food non-signicantly ear- ative intravenous injection of dexamethasone in tonsillectomy
lier than patients of the control group (1.8 h vs. 2.3 h after sur- patients reduces postoperative tonsillectomy pain.
gery, p = 0.218). Solid food intake for patients of the study As regards the use of dexamethasone preoperatively and
was signicantly earlier than patients of the control group the reported benecial effect supported those reported by mul-
(4.8 h vs. 6.0 h after surgery, p = 0.05) (Table 4). tiple previous studies.19,20,22,23
The overall mean of pain scores and PONV incidences were The mode of action of dexamethasone was still not fully
less in the study group as compared to the control group, when understood, however, it is believed to involve the anti-emetic
data for all the seven days, since operation day, were com- and analgesic action of dexamethasone and could be attributed
pared. Furthermore, none of the patients of the study group to the central inhibition of prostaglandin synthesis, changes in
complained of any side effects post-surgery. the permeability of the blood cerebrospinal uid barrier to ser-
um protein, and/or a decrease in serotonin turnover in the cen-
5. Patient outcome tral nervous system. In conjunction with antiemetic and
analgesic effects, dexamethasone also reduces inammation
Patients of both, the study and control groups recovered from at the operative site, subsequently reducing the release of
anesthesia without any complications. All patients were medi- inammatory mediators into the circulation. This is also be-
cated with postoperative antibiotics, antiemetics, and analge- lieved to possibly lead to less stimulation of the vomiting cen-
sics as per the protocol mentioned in the methodology ter in the brain. Dexamethasone causes inhibition of the
section. All patients were discharged on the second day post- inammatory response by blocking factors such as bradykinin,
surgery. prostaglandin, and leukotrienes, which result in a decreased le-
vel of inammation and reduction of the accompanying signs
and symptoms including pain.24,25
6. Discussion
Recently, Vaiman et al.26,27, evaluated the efcacy and
safety of oxycodone and dexamethasone in pain management
Preoperative dexamethasone signicantly reduced PONV and after tonsillectomy using surface electromyographic (sEMG)
postoperative pain compared to control group. Moreover, pa- study of post-tonsillectomy swallow-evoked muscular reac-
tients received dexamethasone could take oral liquids and solid tions and reported that application of dexamethasone is advis-
food signicantly earlier than those of the control group. able because of the reduction of postoperative morbidity with
These data are in agreement with that previously reported reduction of the postoperative pain which is secondary to the
concerning the efcacy of dexamethasone as postoperative reduction of edema. Moreover dexamethasone normalizes
analgesic and for management of PONV after various types muscular activity in deglutition as detected by the sEMG re-
of surgery; Mathiesen et al.14,15 reported signicant reduction cords with statistically signicant difference in muscle reac-
of both frequency and severity of PONV after hip arthroplasty tions between patients received dexamethasone and placebo
and laparoscopic hysterectomy, respectively, in patients re- thus improving the action of deglutition muscle thus allowing
ceived dexamethasone compared to those received pregabalin early oral intake.
or placebo with signicantly higher sedation scores with
pregabalin.
7. Conclusions
Worni et al.16 found a preoperative single dose of dexa-
methasone signicantly reduced nausea, vomiting, and pain,
and improved postoperative voice function within the rst Results of this study suggest that a single preoperative injec-
48 h after thyroid resection. Czarnetzki et al.17 documented tion of dexamethasone in a dose of 0.3 mg/kg with a maximum
that dexamethasone decreased the risk of PONV dose depen- dose of 8 mg for adult patients, undergoing tonsillectomy by
dently but was associated with an increased risk of postopera- cold dissection method, signicantly reduced postoperative
tive bleeding in children undergoing tonsillectomy. pain and nausea and vomiting and allowed early resumption
Fukami et al.18 suggested that preoperative dexamethasone of oral intake without side effects and could be advocated as
signicantly reduces the incidence of PONV, pain, and fatigue a sole analgesic modality for such patients.
after laparoscopic cholecystectomy and concluded that the em-
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