Effects of Oral Prednisolone on Recovery After Tonsillectomy

Soo K. Park, MD; Jisung Kim, MD; Jeong M. Kim, MD;

Je Y. Yeon, MD; Woo S. Shim, MD; Dong W. Lee, MD

Presentant :
Aldityas Eko Wibawanto

Consultant :
dr. Vicky Eko N H, MSc, SpTHT-KL

SPECIALIST EDUCATION PROGRAM ENT HEAD AND NECK SURGERY

FACULTY OF MEDICINE SEBELAS MARET UNIVERSITY
DR MOEWARDI HOSPITAL
SURAKARTA
2015
Introduction

• Tonsillectomy remains one of the most common

procedures

• Post-operative morbidities  post-operative

hemorrhage, pain, nausea or vomiting,
velopharyngeal incompetency, reduced oral intake,
and decrease in the frequency of social activity
 • Secondary infection can also be induced at
tonsillectomy sites if wound healing is poor or
delayed.

• Dexamethasone can be administered during

or after elective tonsillectomy to reduce post-
Steward et al., 2001;
operative emesis and decrease post
Goldman et al., 2000 operative use of pain medications.
 • No consensus on whether an orally
administered steroid should be used routinely
after tonsillectomy. These studies have had
Palme et al., 2000; small sample sizes, a short follow up period
Macassey et al.,
2012 and have not reported objective findings.
Objective
• to evaluate the effect of oral
prednisolone on recovery from
tonsillectomy
Materials and Methods

• 198 patients (aged 4 years old and older) with no

Sample previous or known contraindications to steroid
therapy

Period • April 2013 – April 2014

Location • Chungbuk National University College of Medicine,

Cheongju, Korea
 Inclusion Criteria Exclusion Criteria
- Patient who did not consent to
- All Patients aged 4 years and older participate
were scheduled for elective
tonsillectomy with or without - Active infection
adenoidectomy - Known contraindications to steroid use
- A history of steroid therapy within the
past 1 year
Methods

Post-operative course of
Using a questionnaires and
prednisolone 0.25 mg/kg/d
The patients were measurement of the wound
or no prednisolone on day 1
randomized into two groups healing process by
and were follow up on days
endoscopic photograph
7 and 14

Using the standard

All analyses were
Using the Student t test deviation in the pain score
performed using SPSS
and the x2 test. and two sided .05 level of
version 21 .
significance
Figure 1. Questionnaires administered to adult and pediatric subjects
Figure 2. (A). Example of how healing of the left tonsillar fossa was
estimated from an endoscopic photograph without a superimposed grid.
(B). Example of how healing of the left tonsillar fossa was estimated from
an endoscopic photograph with a superimposed grid.
Results

198 patients

99 patients in
each group

69 pediatrics
and 30 adults
 Table 1. Patient Demographics and Characteristics

Factor Control, Prednisolone, P Value

n = 30 n = 30
Adult
Average age ± SD, yr 27.60 ± 7.62 28.07 ± 8.18 .82
Sex .11
Male 9 16
Female 21 14
Indication for tonsillectomy .61
Hypertrophy 3 1
Tonsillitis 27 29
 Control, Prednisolone, P Value
n = 69 n = 69
Pediatric
Average age ± SD, yr 7.48 ± 2.07 7.90 ± 4.10 .50
Sex .14
Male 51 42
Female 18 27
Indication for tonsillectomy .06
Hypertrophy 62 68
Tonsillitis 7 1
 Table 2. Patient Characteristics on Day 1

Factor Control Prednisolone P Value

Adults
Pain score, 5.67 ± 1.66 5.57 ± 1.85 .82
0 to 10 ± SD
Diet
None 4 0 .70
Fluid 7 13
Soft 18 15
Normal 1 2
Activity
None 0 7 .1.00
Quiet 21 10
Restricted 9 9
Normal 0 4
 Control Prednisolone P Value

Minor bleeding, % 5.5 5.5 1.00

Nausea/vomiting, % 4.5 5.5 .14

Fever, % 11.0 11.0 .18

Sleep disturbance, % 4.0 4.0 1.00

 Control Prednisolone P Value
Pediatric
Pain score, 2.94 ± 1.81 3.38 ± 1.80 .15
0 to 10 ± SD
Diet
None 0 1 .30
Fluid 6 9
Soft 63 57
Normal 0 2
Activity
None 5 6 .92
Quiet 24 24
Restricted 27 28
Normal 13 11
Minor bleeding, % 14.1 13.9 .86
Nausea/vomiting, % 13.6 13.4 .18
Fever, % 15.6 15.4 .05
Sleep disturbance, % 14.6 14.4 .20
 Table 3. Patient Characteristics on Day 7

Factor Control Prednisolone P Value

Adult
Pain score, 3.83 ± 1.48 3.17 ± 2.19 .17
0 to 10 ± SD
Diet
None 0 0 .37
Fluid 2 2
Soft 25 21
Normal 3 7
Activity
None 1 0 .04*
Quiet 4 2
Restricted 21 15
Normal 4 13
 Control Prednisolone P Value

Re-epithelialization area, 23.93 ± 2.59 38.27 ± 3.22 < .001*

% ± SD

Minor bleeding, % 8.5 8.5 .25

Nausea/vomiting, % 2.1 3.0 .03*

Fever, % 2.0 2.0 .12

Sleep disturbance, % 9.0 9.0 .15

 Control Prednisolone P Value
Pediatric
Pain score, 2.64 ± 2.60 1.39 ± 1.50 .001*
0 to 10 ± SD
Diet
None 0 0 .001*
Fluid 11 1
Soft 41 36
Normal 17 32
Activity
None 0 0 .004*
Quiet 14 2
Restricted 16 15
Normal 39 52
 Control Prednisolone P Value

Re-epithelialization area, 24.58 ± 3.70 48.03 ± 7.41 < .001*

% ± SD
Minor bleeding, % 16.0 16.0 .31

Nausea/vomiting, % 10.0 10.0 1.00

Fever, % 7.2 9.5 .04*

Sleep disturbance, % 7.3 9.5 .04*

 Table 4. Patient Characteristics on Day 14

Factor Control Prednisolone P Value

Adult
Pain score, 0 to 10 ± SD 2.27 ± 1.72 2.27 ± 1.14 1.00
Diet
None 0 0 .19
Fluid 0 0
Soft 10 16
Normal 20 14
Activity
None 0 0 .77
Quiet 1 0
Restricted 8 10
Normal 21 20
 Control Prednisolone P Value

Re-epithelialization area, 58.37 ± 4.93 76.63 ±3.37 < .001*

% ± SD
Minor bleeding, % 6.0 6.0 1.00

Nausea/vomiting, % 5.0 5.0 .73

Fever, % 2.0 2.0 .12

Sleep disturbance, % 11.0 11.0 .78

 Control Prednisolone P Value
Pediatric
Pain score, 0 to 10 ± SD 0.42 ± 0.83 0.12 ± 0.58 .01*
Diet
None 0 0 .73
Fluid 0 0
Soft 4 5
Normal 65 64
Activity
None 0 0 .24
Quiet 0 0
Restricted 3 0
Normal 66 69
Re-epithelialization area, % ± SD 68.00 ± 4.11 86.93 ± 3.65 < .001*
Minor bleeding, % 2.5 2.5 .06
Nausea/vomiting, % 1.0 0.5 1.00
Fever, % 3.0 1.5 1.00
Sleep disturbance, % 4.0 2.0 .12
 Table 5. Characteristics of Hypertrophy and Tonsillitis Patients on day 7

Factor Control, n = 65 Prednisolone, n = 69 P Value

Hypertrophy
Pain score, 0 to 10 ± SD 2.71 ± 2.65 1.42 ± 1.53 < .001*
Diet
None 0 0 .003*
Fluid 10 1
Soft 38 36
Normal 17 32
Activity .005*
None 0 0
Quiet 13 2
Restricted 15 15
Normal 37 52
 Control, n = 65 Prednisolone, n = 69 P Value

Re-epithelialization area, 24.62 ± 3.82 47.90 ± 7.59 <. 001*

% ± SD
Minor bleeding, % 15.0 16.0 .31

Nausea/vomiting, % 9.2 9.8 1.00

Fever, % 8.2 7.2 .09

Sleep disturbance, % 9.2 9.8 .34

 Control, n = 34 Prednisolone, n =30 P Value
Tonsillitis
Pain score, 0 to 10 ± SD 3.56 ± 1.61 3.10 ± 2.20 .34
Diet
None 0 0 .27
Fluid 3 2
Soft 28 21
Normal 3 7
Activity
None 1 0 .09
Quiet 5 2
Restricted 22 15
Normal 6 13
Re-epthelialization area, % ± SD 23.94 ± 2.41 38.57 ± 3.13 < .001*
Minor bleeding, % 9.6 8.4 .17
Nausea/vomiting, % 7.0 3.3 .01*
Fever, % 3.2 2.8 .02*
Sleep disturbance, % 9.6 8.4 .26
Discussion

Oral steroid (Prednisolone) is easier to

administer and can be given to tonsillectomy
patients as a post-operative course.
The recipients of oral prednisolone on day 7 and
14 were reported statistically significant
reduction in pain, faster rate of return to a normal
diet, daily activities, fewer episodes fever, sleep
disturbance and better wound healing process.
Conclusion

Oral prednisolone may offer benefits to patients

and help their recovery after tonsillectomy.
General Description
Design :
Prospective, randomized, controlled trial
Sample :
198 patients (aged 4 years and older) were
scheduled for elective tonsillectomy, with no
previous or known contraindications to
steroid therapy
Title :
Interesting, concise, straightforward
Authors :
clearly written constitution. There is a
correspondence address
Abstract :
clear and appropriate rules
Introduction :
it consists more than two paragraphs and the
rules, it contains the purpose of the study
PICO

Population :
patients aged 4 years and older were
scheduled for tonsillectomy, with no previous or
known contraindications to steroid therapy
Intervention :
oral prednisolone and endoscopic photograph
examination
Compare :
prednisolone and control groups
Outcome :
recovery to normal life, reducing morbidities
and better wound healing process
Are the results of the trial valid ?
1. Was the assignment of patients to treatment randomized ? Yes

2. Were the groups similar at the start of the trial ? Yes

3. A side from the allocated treatment, were groups treated Yes

equally ?

4. Were all patients who entered the trial accounted for ? And Yes
were they analyzed in the roups to which they were
randomized

5. Were measures objective or were the patients and clinician No

kept blind to which treatment was being received ?
What were the results ?
1. How large was the treatment effect ?
The treatment effect was reported that it had significant
benefits in pain control, reducing morbidities, recovery to
a normal life and better wound healing process.
2. How precise was the estimate of the treatment
effect ?
The estimate of the treatment effect was level of
significance .05 ( p value .05).
3. Will the results help me in caring for my patient ?
Yes
For the conclusion, the journal is valid, important
and applicable.
Why steroid ?
…significant edema and inflammation occur in
the operative bed. Steroid medications
nonspecifically reduce inflammation, and so it
follows that perioperative steroid administration
might be useful in decreasing postoperative
symptoms in patients undergoing tonsillectomy.”

Diane G. Heatley, MD
Arch Otolaryngol Head Neck Surg. 2001
Steroids elevate blood glucose levels by
increasing hepatic glucose production and
inhibiting glucose uptake into muscles. ( Lisa R
et al., 2012)
Oral steroids (glucocorticoids) are naturally
produced by the adrenal cortex which is
important in the metabolism of food and water.
They have therapeutic effects as anti-
inflammatory and anti-allergic agents and are
therefore extensively used to treat a variety of
medical conditions (Palme et al., 2000)
Glucocorticoids cause inhibition of the overall
inflammatory response by blocking factors such
as bradykinin, prostaglandin, and leukotrienes,
which can cause tissue edema and nerve
irritation. This potentially results in a lessening in
the degree of inflammation and its
accompanying signs and symptoms. It has been
proposed that steroids, which are safe in the
short-term and may be of use in recovery from
tonsillectomy. (Palme et al., 2000)
Limitation of the study

It was not performed as a double blind study 

biases
The measurement of healing was not completely
objective because gross appearance and color
were only used to determine re-epithelialization