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
of postoperative nausea and vomiting (PONV) are associated
with severe pain causing local inammation, venous hyperten-
sion, hemorrhage, and pulmonary aspiration.4 Despite the
availability of various analgesic and antiemetic regimens
post-tonsillectomy, patient surveys have indicated that moder-
ate-to-severe postoperative pain is still poorly managed.5
Results of many published clinical studies provide evi-
dences regarding the benecial effects of steroids with regard
to decreasing episodes of nausea, vomiting and pain, following
tonsillectomy.6,7 Of all steroids, glucocorticoids have the most
powerful anti-inammatory characteristics. Administration of
corticosteroid regimens has been proved to be safe and effec-
tive in managing mild-to-moderate postoperative pain man-
agement after tonsillectomy with no contraindications to
their use.8,9 Dexamethasone is a potential glucocorticoid drug
that acts as an anti-inammatory and immunosuppressive
agent. The prolonged analgesic and antiemetic effects of dexa-
methasone help to improve the quality of life in adult patients
post-tonsillectomy by reducing the tissue damage and local
inammation by blocking the inammatory mediators, prosta-
glandin antagonism, release of endorphins, and tryptophan
depletion. Many previously published studies have further
conrmed that single, low dose intravenous administration
of dexamethasone, prior to tonsillectomy, during the induction
of anesthesia, considerably reduces postoperative morbidities
such as pain, nausea, and vomiting, and improves quality of
oral food intake.1013
This study was conducted in an aim to investigate the ef-
cacy of a single dose of dexamethasone administered intrave-
nously prior to tonsillectomy, on postoperative nausea,
vomiting, and pain on the quality of oral intake in a group
of adult patients undergoing cold dissection tonsillectomy,
using a standardized anesthetic and surgical procedure. Re-
sults obtained from the study and control groups were com-
pared to determine if the preoperative administration of
dexamethasone is benecial in reducing postoperative
morbidities.
2. Materials and methods
The current randomized controlled clinical trial was con-
ducted at the Department of Otorhinolaryngology, Ain-
Shams University Hospital, Egypt, during 20062011. The
selection criteria for this study included adult patients of
age 1565 years, weighing 40100 kg, ASA (American Soci-
ety of Anesthesiologists) physical status I and II, undergoing
elective tonsillectomy. Patients with suspected malignancy
and those with contraindication in using non-steroidal
anti-inammatory drugs were excluded from the study.
Thus, after obtaining approval from the hospitals ethics
committee and informed consent from patients, a total of
106 adult patients (65 males and 41 females) were enrolled
for the study.
For standardization of the study outcome, all surgeries
were conducted by the same surgeon and anesthetic procedure
was the same for all patients and was performed by one anes-
thetist. Patients were randomly, using sealed envelops, allo-
cated into study and control groups (53 patients in each
group), i.e., patients were randomized to receive either dexa-
methasone (study group) or an equivalent volume of normal
saline (control group). General anesthetic procedure was
A.H. Khafagy, S.M. Osman
followed by surgeons for both groups prior to the surgery. Pa-
tients of the study group received the corticosteroid dexameth-
asone (Decadron MSD) intravenously in a single dose of
0.3 mg/kg, maximal dose 8 mg, 15 min prior to start of the sur-
gery, during the induction of general anesthesia while the con-
trol group did not receive any steroids. Patients of the control
group were injected with the similar amount, i.e., 2 ml of nor-
mal saline solution during anesthetic induction. The cold dis-
section technique was followed for the tonsillectomy and
general postoperative measures were standardized for both
groups.
All patients were discharged after 24 h stay in hospital,
post-tonsillectomy. Patients were prescribed with the following
oral medication (analgesics and antiemetics), for relief from
pain and vomiting, during and after their hospital stay, till se-
ven days duration, post-surgery.
 Paracetamol tablets (1 g every 6 h)
 Diclofenac dispersible (50 mg every 8 h)
 Dihydrocodeine (30 mg every 6 h interval/day)
Patients were asked to ll in a written questionnaire, where
they had to note the time of their rst intake of solid and liquid
food after surgery along with incidences of nausea, vomiting,
and severity of pain each day, from the day of surgery till
the next seven days. To determine the postoperative extent
of pain in patients, the visual analogue scale (VAS) of pain
scores was used where 0 represented no pain and 10 repre-
sented severe pain. Patients were asked to label a score of
04 for mild pain, 57 for moderate pain, and 810 for severe
pain on the VAS. To assess the postoperative occurrences of
nausea and vomiting (PONV) or incidences of emesis, patients
were asked to note the number of emetic episodes per day.
Three or less episodes per day were considered as mild PONV,
four or more episodes per day were labeled as moderate
PONV, and more than eight episodes per day were marked
as severe PONV. Patients were also asked to note the postop-
erative duration of rst liquid and solid oral food intake as the
delay in postoperative oral uid and solid intake as a result of
nausea, vomiting, or pain prolongs the healing time and in-
creases dehydration risks in early and late postoperative peri-
ods. Based on the comparison of these data, the difference in
healing times between both groups could be determined. These
details were collected from patients when they came to the hos-
pital on the seventh day for their follow-up check-up.
3. Statistical methods
Data analysis was performed using the SPSS (Statistical
Package for the Social Sciences) software, version 17.0. The
data were expressed as mean (standard deviation SD) for
normally distributed data and median (inter-quartile range
IQR) for non-normally distributed data. Mean and standard
deviation were calculated for age and weight of these 74 pa-
tients. The KolmogorovSmirnov test was used to test normal-
ity of the distribution. Paired t-test and Wilcoxon Signed rank
test were applied to examine statistically signicant differences
between the two groups for severity of pain and incidences of
PONV on the day of operation and till seven days post-oper-
ation. P values less than 0.05 were considered to be statistically
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
On the seventh day of follow-up, complete data were obtained
in the form of lled questionnaires only from 74 patients
(70%) out of the 106 operated patients. These data were sub-
sequently used to evaluate and compile the results. Of these 74
patients, 31 patients belonged to the control group and 43 pa-
tients belonged to the study group. All these patients under-
went cold dissection tonsillectomy with single dose
preoperative dexamethasone given in the study group and no
dexamethasone in the control group. The 74 adult patients in-
cluded 48 males and 26 females. There were 20 males (age
group = 1564 years, mean age = 31 years; weight
range = 40100 kg, mean weight = 58 kg) and 11 females
(age group = 1560 years, mean age = 28 years; weight
range = 4083 kg, mean weight = 54 kg) in the control group,
while in the study group there were 28 males (age group = 16
65 yrs, mean age = 34 years; weight range = 4098 kg, mean
weight = 56 kg) and 15 females (age group = 1559 years,
mean age = 29 years; weight range = 4185 kg, mean
weight = 50 kg) (Table 1).
The overall incidence of PONV in the study group showed
a signicant decrease (p = 0.03) of around 65% as compared
to the control group, when data obtained on the operation
day and on the seventh day post-operation were compared
for both groups (Table 2). The postoperative pain score had
also signicantly decreased (p = 0.018) by 26% in the study
group as compared to the control group on the same day of
operation. Further, when the overall pain score after seven
days of operation was measured for both groups, it showed
a signicant decrease by 14.6% (p = 0.003) in the study group
as compared to the control group (Table 3). When the dura-
116
tion of rst liquid and solid food intake, post-tonsillectomy,
was compared in both groups, results showed that patients
of the study group could take liquid food non-signicantly ear-
lier than patients of the control group (1.8 h vs. 2.3 h after sur-
gery, p = 0.218). Solid food intake for patients of the study
was signicantly earlier than patients of the control group
(4.8 h vs. 6.0 h after surgery, p = 0.05) (Table 4).
The overall mean of pain scores and PONV incidences were
less in the study group as compared to the control group, when
data for all the seven days, since operation day, were com-
pared. Furthermore, none of the patients of the study group
complained of any side effects post-surgery.
5. Patient outcome
Patients of both, the study and control groups recovered from
anesthesia without any complications. All patients were medi-
cated with postoperative antibiotics, antiemetics, and analge-
sics as per the protocol mentioned in the methodology
section. All patients were discharged on the second day post-
surgery.
6. Discussion
Preoperative dexamethasone signicantly reduced PONV and
postoperative pain compared to control group. Moreover, pa-
tients received dexamethasone could take oral liquids and solid
food signicantly earlier than those of the control group.
These data are in agreement with that previously reported
concerning the efcacy of dexamethasone as postoperative
analgesic and for management of PONV after various types
of surgery; Mathiesen et al.14,15 reported signicant reduction
of both frequency and severity of PONV after hip arthroplasty
and laparoscopic hysterectomy, respectively, in patients re-
ceived dexamethasone compared to those received pregabalin
or placebo with signicantly higher sedation scores with
pregabalin.
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
48 h after thyroid resection. Czarnetzki et al.17 documented
that dexamethasone decreased the risk of PONV dose depen-
dently but was associated with an increased risk of postopera-
tive bleeding in children undergoing tonsillectomy.
Fukami et al.18 suggested that preoperative dexamethasone
signicantly reduces the incidence of PONV, pain, and fatigue
after laparoscopic cholecystectomy and concluded that the em-
ployed regimen is safe and without apparent side effects. Fujii
and Nakayama19 found dexamethasone is effective in reducing
the rate of PONV and analgesic requirements in adult Japa-
nese patients undergoing middle ear surgery.
Jokela et al.20 reported that IV dexamethasone 15 mg
before induction of anesthesia decreases the oxycodone con-
sumption during the rst 24 h after laparoscopic hysterectomy
and that dexamethasone 10 mg reduces the oxycodone con-
sumption as effectively as the 15 mg dose. Ammar and Wang21
documented that dexamethasone reduces postoperative pain
and odynophagia after tonsillectomy.
Mathiesen et al.22 reported that combination of pregabalin
and dexamethasone reduced post-operative pain scores and
consumption of ketobemidone following tonsillectomy in
A.H. Khafagy, S.M. Osman
adults, but dizziness was increased due to the addition of pre-
gabalin. Buland et al.23 documented that single dose perioper-
ative intravenous injection of dexamethasone in tonsillectomy
patients reduces postoperative tonsillectomy pain.
As regards the use of dexamethasone preoperatively and
the reported benecial effect supported those reported by mul-
tiple previous studies.19,20,22,23
The mode of action of dexamethasone was still not fully
understood, however, it is believed to involve the anti-emetic
and analgesic action of dexamethasone and could be attributed
to the central inhibition of prostaglandin synthesis, changes in
the permeability of the blood cerebrospinal uid barrier to ser-
um protein, and/or a decrease in serotonin turnover in the cen-
tral nervous system. In conjunction with antiemetic and
analgesic effects, dexamethasone also reduces inammation
at the operative site, subsequently reducing the release of
inammatory mediators into the circulation. This is also be-
lieved to possibly lead to less stimulation of the vomiting cen-
ter in the brain. Dexamethasone causes inhibition of the
inammatory response by blocking factors such as bradykinin,
prostaglandin, and leukotrienes, which result in a decreased le-
vel of inammation and reduction of the accompanying signs
and symptoms including pain.24,25
Recently, Vaiman et al.26,27, evaluated the efcacy and
safety of oxycodone and dexamethasone in pain management
after tonsillectomy using surface electromyographic (sEMG)
study of post-tonsillectomy swallow-evoked muscular reac-
tions and reported that application of dexamethasone is advis-
able because of the reduction of postoperative morbidity with
reduction of the postoperative pain which is secondary to the
reduction of edema. Moreover dexamethasone normalizes
muscular activity in deglutition as detected by the sEMG re-
cords with statistically signicant difference in muscle reac-
tions between patients received dexamethasone and placebo
thus improving the action of deglutition muscle thus allowing
early oral intake.
7. Conclusions
Results of this study suggest that a single preoperative injec-
tion of dexamethasone in a dose of 0.3 mg/kg with a maximum
dose of 8 mg for adult patients, undergoing tonsillectomy by
cold dissection method, signicantly reduced postoperative
pain and nausea and vomiting and allowed early resumption
of oral intake without side effects and could be advocated as
a sole analgesic modality for such patients.
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