ABSTRACT
Objectives
Pain, dehydration, and bleeding remain significant concerns for pediatric tonsillectomy patients. The literature is sparse on potential effects of postoperative, outpatient steroid prescribing practices among the post‐tonsillectomy pediatric population. We aim to investigate the association of a postoperative oral steroid course with pain, bleeding, and dehydration while controlling for infectious indication to guide physicians for appropriate management of this population.
Methods
Single institution, retrospective review of pediatric patients aged 2–18 years who underwent tonsillectomy from 2019 to 2021. One group received a 4‐dose course of postoperative oral dexamethasone, and the other did not. Among patients ages 2–6 and 7–18, the association of steroids with emergency department visits related to bleeding, dehydration, or uncontrolled pain was estimated while controlling for infectious indication and other factors.
Results
There were 2054 pediatric tonsillectomy patients included. The majority were male (50.8%) and Non‐Hispanic White (63.7%) with an average age of 7.0 years (SD = 3.9). About one‐third (30.4%) of patients received dexamethasone, and dexamethasone was not associated with significantly lower odds of bleeding, dehydration, or uncontrolled pain/pain medication refills.
Conclusion
A 4‐dose course of postoperative dexamethasone was not associated with a significant reduction in post‐tonsillectomy bleeding, dehydration, or pain when controlling for infectious indication. However, it may be reasonable as an adjunct therapy.
Level of Evidence
3.
Keywords: dexamethasone, pediatric tonsillectomy, postoperative steroids, post‐tonsillectomy complications
1. Introduction
There are approximately 289,000 tonsillectomies performed annually in children, making this the third most common pediatric surgical procedure in the United States [1, 2, 3, 4]. Despite its prevalence, postoperative morbidities such as pain, nausea, vomiting, and secondary hemorrhaging are still commonly experienced and remain a significant concern for both patients and their parents [5, 6]. From database studies, the median 30‐day return rate for post‐tonsillectomy bleeding and dehydration is 7.8%, with individual institution rates varying from 3.0% to 12.6%, and overall late‐complication return rates as high as 13.3% [7, 8]. This can cause the global healthcare cost of tonsillectomies to be as much as 10% higher than the perioperative costs [6, 7, 8]. The most common morbidity after tonsillectomy is pain, which was identified as a top concern for more than 90% of parents [9, 10]. Many studies have analyzed various medical interventions such as steroids for reducing these morbidities in the immediate postoperative period, including systematic reviews and meta‐analyses [10]. Based on these studies, current guidelines recommend administering a single intraoperative dose of intravenous dexamethasone, as this has been proven to aid in the reduction of postoperative nausea, pain, and swelling [9, 11, 12, 13]. However, the literature is sparse on the effects of postoperative, outpatient steroid prescribing practices among the post‐tonsillectomy pediatric population.
Papangelou et al. first proposed the benefit of oral steroids in this population in 1972 [14]. More recently, there have been few studies on this subject with heterogeneous patient populations, steroid dosing regimens, and conflicting results [5, 9, 11, 15, 16, 17, 18, 19]. Further, tonsillectomy recovery may differ by indication. Infectious indications likely inherently involve altered/scarred tissue planes which may affect subjective postoperative pain and related complication rates [20]. One recent study demonstrated a significant decrease in parental phone calls by 9% and bleed rates by 4% in pediatric post‐tonsillectomy patients receiving 0.5 mg/kg dexamethasone for 3 doses compared to their counterparts not receiving steroids [19]. However, this study did not control for infectious indication for tonsillectomy. Given the relative sparsity of data on this subject, and the conflicting data of previous studies with heterogeneous patient populations and treatment protocols, we sought to investigate this topic further. Indeed, to our knowledge, this is the largest study in literature analyzing the association of postoperative oral steroids with tonsillectomy recovery. It has the additional benefit of analyzing a standardized postoperative oral dexamethasone dosing regimen on specifically pediatric patients undergoing monopolar cautery tonsillectomy, based on tonsillectomy indication. Furthermore, we specifically analyze complications that concretely led to a postoperative physician intervention including emergency department visits for bleeding, dehydration, uncontrolled pain, and pain medication refills. We seek to provide guidance to physicians for appropriate management of postoperative complications among post‐tonsillectomy pediatric patients.
2. Materials and Methods
2.1. Data Source
This was a retrospective review of Electronic Medical Records for all children undergoing tonsillectomy (either alone or with adenoidectomy) at a single academic tertiary care pediatric hospital from June 1, 2019 to October 31, 2021, among pediatric otolaryngology physicians who use the same operative technique (monopolar electrocautery for tonsillectomy and suction electrocautery for adenoidectomy). Typical monopolar electrocautery settings ranged from 15 to 16 W for tonsillar dissection and up to 20–24 W as needed for hemostasis; settings were not standardized across surgeons. All indications (infectious, obstructive sleep apnea (OSA), sleep disturbance (SDB), infectious and OSA, infectious and SDB) were included, and only pediatric patients from ages 2–18 were included in the data retrieval. These children were stratified into one group that received a postoperative steroid course (0.5 mg/kg dexamethasone q48hrs for 4 doses with a maximum of 20 mg per dose and a minimum of 4 mg per dose) and one group that did not receive a postoperative steroid course. Furthermore, all patients were prescribed a standard dose of acetaminophen and ibuprofen at 15 and 10 mg/kg respectively; however, an adjustment would be made to select patients based on weight. Patients 7 years and older were additionally prescribed low dose oxycodone (0.05 mg/kg/dose) to be taken as needed for severe breakthrough pain. It was very rare that patients aged 2 to 6 years old were prescribed oxycodone, and there were no refills in this population.
2.2. Measures
The outcomes of interest for this study were whether pediatric tonsillectomy patients received steroids (yes, no) and whether they experienced any post‐tonsillectomy complications (bleeding, dehydration, uncontrolled pain/opioid refill, and other). Bleeding was defined as the presence of active bleeding of tonsils requiring hemorrhage control or the presence of bloody clots on tonsillar tissue seen during an ED visit. Dehydration was defined by the emergency room provider's notes documenting low fluid intake or a diagnosis of dehydration upon arriving at the emergency room. For patients ages 7–18, uncontrolled pain was defined as having an emergency department visit for uncontrolled pain or asking for a pain medication refill. However, since patients ages 2–6 rarely were prescribed opioids, uncontrolled pain was only defined as having an emergency department visit for uncontrolled pain for those patients. Other variables of interest included age at tonsillectomy (years), gender (female, male), race/ethnicity (Hispanic, Non‐Hispanic Black, Non‐Hispanic White, Non‐Hispanic Other, Non‐Hispanic Unknown), indication for tonsillectomy (listed previously), and comorbidities (obesity, asthma, developmental delay/autism, neurologic issues, heart disease, lung disease, and bleeding disorder).
2.3. Statistical Analysis
Patient characteristics were summarized overall and by age group using counts/percentages or means/standard deviations as appropriate. Crude odds ratios (CORs) and 95% confidence intervals (CIs) from logistic regression compared the odds of receiving steroids, bleeding, and dehydration by age group. Because uncontrolled pain was defined differently for patients 2–6 and 7–18, no age group comparison was made for this complication. CORs and 95% CIs from logistic regression estimated age‐specific associations of receiving steroids, tonsillectomy indication, and other relevant patient factors with bleeding, dehydration, and uncontrolled pain. Adjusted odds ratios (AORs) and 95% CIs from multivariable logistic regression also estimated these age‐specific associations while controlling for the effects of other variables used in the crude comparisons. For CORs, Firth's bias correction was used for any models where there were fewer than 10 events per parameter estimate or if the maximum likelihood model did not converge. For AORs, all models had fewer than 10 events per parameter estimate, so Firth's bias correction was used for all AORs. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). All tests were two‐tailed with α = 0.05.
3. Results
3.1. Overall Patient Characteristics
There were 2054 pediatric tonsillectomy patients included in this study. Most patients were male (50.8%), Non‐Hispanic White (63.7%), and ages 2–6 (61.1%). The average age was 7.0 years (standard deviation 3.9 years). The most common indication for tonsillectomy was OSA only (42.2%), followed by SDB only (32.5%), infection only (11.7%), infection and SDB (10.4%), and infection and OSA (3.3%); about one‐quarter (25.4%) had an infectious indication. The most common comorbidity was obesity (26.8%), followed by asthma (11.3%), developmental delay/autism (8.9%), neurologic issues (4.6%), heart disease (2.1%), lung disease (1.5%), Trisomy 21 (1.0%), and bleeding disorder (0.1%) (Table 1).
TABLE 1.
Patient characteristics stratified by age and steroids.
| Mean (SD) or n (Column %) | |||||||
|---|---|---|---|---|---|---|---|
| Age 2–6 | Ages 7–18 | ||||||
| n = 1255 | n = 799 | All patients | |||||
| (61.1%) | (38.9%) | n = 2054 | |||||
| No | Received | No | Received | All 7–18 | Total | ||
| Steroids | Steroids | Steroids | Steroids | ||||
| n = 889 | n = 366 | n = 540 | n = 259 | ||||
| (70.8%) | (29.2%) | All 2–6 | (67.6%) | (32.4%) | |||
| Age (Years) | 4.4 (1.4) | 4.4 (1.4) | 4.4 (1.4) | 11.0 (3.1) | 10.9 (3.1) | 11.0 (3.1) | 7.0 (3.9) |
| Gender | |||||||
| Male | 481 (54.1%) | 201 (54.9%) | 682 (54.3%) | 236 (43.7%) | 125 (48.3%) | 361 (45.2%) | 1043 (50.8%) |
| Female | 408 (45.9%) | 165 (45.1%) | 573 (45.7%) | 304 (56.3%) | 134 (51.7%) | 438 (54.8%) | 1011 (49.2%) |
| Race/Ethnicity | |||||||
| Hispanic | 32 (3.6%) | 14 (3.8%) | 46 (3.7%) | 26 (4.8%) | 5 (1.9%) | 31 (3.9%) | 77 (3.7%) |
| Non‐Hispanic Black | 178 (20.0%) | 105 (28.7%) | 283 (22.5%) | 145 (26.9%) | 96 (37.1%) | 241 (30.2%) | 524 (25.5%) |
| Non‐Hispanic White | 607 (68.3%) | 219 (59.8%) | 826 (65.8%) | 337 (62.4%) | 145 (56.0%) | 482 (60.3%) | 1308 (63.7%) |
| Non‐Hispanic Other | 10 (1.1%) | 3 (0.8%) | 13 (1.0%) | 5 (0.9%) | 2 (0.8%) | 7 (0.9%) | 20 (1.0%) |
| Non‐Hispanic Unknown | 62 (7.0%) | 25 (6.8%) | 87 (6.9%) | 27 (5.0%) | 11 (4.2%) | 38 (4.8%) | 125 (6.1%) |
| Tonsillectomy Indication | |||||||
| Infection Only | 67 (7.5%) | 20 (5.5%) | 87 (6.9%) | 112 (20.7%) | 41 (15.8%) | 153 (19.1%) | 240 (11.7%) |
| Infection and OSA | 15 (1.7%) | 7 (1.9%) | 22 (1.8%) | 36 (6.7%) | 10 (3.9%) | 46 (5.8%) | 68 (3.3%) |
| Infection and SDB | 66 (7.4%) | 32 (8.7%) | 98 (7.8%) | 70 (13.0%) | 45 (17.4%) | 115 (14.4%) | 213 (10.4%) |
| OSA only | 408 (45.9%) | 144 (39.3%) | 552 (44.0%) | 208 (38.5%) | 106 (40.9%) | 314 (39.3%) | 866 (42.2%) |
| SDB only | 333 (37.5%) | 163 (44.5%) | 496 (39.5%) | 114 (21.1%) | 57 (22.0%) | 171 (21.4%) | 667 (32.5%) |
| Obese | |||||||
| No | 737 (82.9%) | 299 (81.7%) | 1036 (82.5%) | 323 (59.8%) | 145 (56.0%) | 468 (58.6%) | 1504 (73.2%) |
| Yes | 152 (17.1%) | 67 (18.3%) | 219 (17.5%) | 217 (40.2%) | 114 (44.0%) | 331 (41.4%) | 550 (26.8%) |
| Asthma | |||||||
| No | 822 (92.5%) | 333 (91.0%) | 1155 (92.0%) | 447 (82.8%) | 220 (84.9%) | 667 (83.5%) | 1822 (88.7%) |
| Yes | 67 (7.5%) | 33 (9.0%) | 100 (8.0%) | 93 (17.2%) | 39 (15.1%) | 132 (16.5%) | 232 (11.3%) |
| Neurologic issues | |||||||
| No | 839 (94.4%) | 352 (96.2%) | 1191 (94.9%) | 521 (96.5%) | 248 (95.8%) | 769 (96.2%) | 1960 (95.4%) |
| Yes | 50 (5.6%) | 14 (3.8%) | 64 (5.1%) | 19 (3.5%) | 11 (4.2%) | 30 (3.8%) | 94 (4.6%) |
| Heart disease | |||||||
| No | 865 (97.3%) | 359 (98.1%) | 1224 (97.5%) | 531 (98.3%) | 256 (98.8%) | 787 (98.5%) | 2011 (97.9%) |
| Yes | 24 (2.7%) | 7 (1.9%) | 31 (2.5%) | 9 (1.7%) | 3 (1.2%) | 12 (1.5%) | 43 (2.1%) |
| Lung disease | |||||||
| No | 872 (98.1%) | 356 (97.3%) | 1228 (97.8%) | 537 (99.4%) | 258 (99.6%) | 795 (99.5%) | 2023 (98.5%) |
| Yes | 17 (1.9%) | 10 (2.7%) | 27 (2.2%) | 3 (0.6%) | 1 (0.4%) | 4 (0.5%) | 31 (1.5%) |
| Developmental delay/Autism | |||||||
| No | 785 (88.3%) | 327 (89.3%) | 1112 (88.6%) | 510 (94.4%) | 250 (96.5%) | 760 (95.1%) | 1872 (91.1%) |
| Yes | 104 (11.7%) | 39 (10.7%) | 143 (11.4%) | 30 (5.6%) | 9 (3.5%) | 39 (4.9%) | 182 (8.9%) |
| Bleeding disorder | |||||||
| No | 889 (100.0%) | 366 (100.0%) | 1255 (100.0%) | 539 (99.8%) | 258 (99.6%) | 797 (99.7%) | 2052 (99.9%) |
| Yes | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (0.2%) | 1 (0.4%) | 2 (0.3%) | 2 (0.1%) |
| Trisomy 21 | |||||||
| No | 875 (98.4%) | 362 (98.9%) | 1237 (98.6%) | 538 (99.6%) | 258 (99.6%) | 796 (99.6%) | 2033 (99.0%) |
| Yes | 14 (1.6%) | 4 (1.1%) | 18 (1.4%) | 2 (0.4%) | 1 (0.4%) | 3 (0.4%) | 21 (1.0%) |
Abbreviations: OSA, Obstructive sleep apnea; SD, Standard deviation; SDB: Sleep disordered breathing.
3.2. Steroids and Complications
Slightly less than one‐third of patients received steroids post‐tonsillectomy (total 30.4%, ages 2–6 29.2%, ages 7–18 32.4%); the odds of receiving steroids did not differ by age (COR = 1.17, 95% CI 0.96–1.41). Overall, the most common complication was bleeding (5.0%), followed by dehydration (3.9%) and uncontrolled pain (1.4%). For ages 2–6, dehydration was the most common complication (5.0%), followed by bleeding (3.9%) and uncontrolled pain (0.9%). For ages 7–18, bleeding was the most common complication (6.8%), followed by dehydration (2.3%) and uncontrolled pain (2.3%). Ages 7–18 had significantly higher odds of experiencing bleeding than ages 2–6 (COR = 1.78, 95% CI 1.20–2.66), while they had significantly lower odds of experiencing dehydration (COR = 0.44, 95% CI 0.25–0.73) (Figure 1). Other complications included pneumonia, tongue swelling, and constipation (all less than 0.1%).
FIGURE 1.
Age‐specific percentages of pediatric tonsillectomy patients who received steroids or experienced complications (bleeding, dehydration, uncontrolled pain). Odds ratios (OR) and 95% confidence intervals (CI) compare the odds of each outcome among ages 7–18 to the odds among ages 2–6. *The two age groups could not be compared in terms of their odds of uncontrolled pain because this outcome was defined as having an emergency department visit for uncontrolled pain among ages 2–6, while among ages 7–18 it also included oxycodone refill.
3.3. Complications by Steroid and Age
Among ages 2–6, the odds of bleeding (AOR = 0.97, 95% CI 0.49–1.80), dehydration (AOR = 0.60, 95% CI 0.31–1.09), and uncontrolled pain (AOR = 0.69, 95% CI 0.13–2.46) were not significantly different between patients who received steroids and those who did not receive steroids. This was also true for ages 7–18 (bleeding AOR = 0.67, 95% CI 0.34–1.25; dehydration AOR = 0.87, 95% CI 0.29–2.26; uncontrolled pain AOR = 0.99, 95% CI 0.33–2.60) (Figure 2).
FIGURE 2.
Associations of receiving steroids with bleeding, dehydration, and uncontrolled pain. AOR: Adjusted odds ratio. CI: Confidence interval. COR: Crude odds ratio. *For ages 2–6, uncontrolled pain was defined as having an emergency department visit for uncontrolled pain, while among ages 7–18 it also included oxycodone refill.
3.4. Complications by Indication and Age
Among patients ages 2–6, those with both infection and OSA as their indication for tonsillectomy had significantly higher odds of dehydration than those with only infection (AOR = 4.82, 95% CI 1.09–21.48). Among patients ages 7–18, those with OSA as their only indication for tonsillectomy had significantly lower odds of having uncontrolled pain compared to those with only infection (AOR = 0.21, 95% CI 0.06–0.78) (Table 2).
TABLE 2.
Association of tonsillectomy indication with bleeding, dehydration, and uncontrolled pain.
| Bleeding | ||||||
|---|---|---|---|---|---|---|
| Age 2–6 | Age 7–18 | |||||
| % | COR (95% CI) | AOR (95% CI) | % | COR (95% CI) | AOR (95% CI) | |
| Infection | 4.6% | Reference | Reference | 9.8% | Reference | Reference |
| Infection and OSA | 0.0% | 0.41 (0.003–4.09) | 0.36 (0.003–3.62) | 8.7% | 0.88 (0.24–2.57) | 1.03 (0.30–2.99) |
| Infection and SDB | 4.1% | 0.88 (0.22–3.52) | 0.85 (0.21–3.42) | 3.5% | 0.33 (0.09–0.94) | 0.39 (0.12–1.07) |
| OSA | 4.7% | 0.93 (0.37–2.99) | 1.00 (0.38–3.29) | 5.4% | 0.53 (0.26–1.10) | 0.73 (0.33–1.64) |
| SDB | 3.0% | 0.60 (0.22–1.98) | 0.62 (0.22–2.10) | 8.2% | 0.82 (0.38–1.77) | 1.02 (0.46–2.26) |
| Dehydration | ||||||
|---|---|---|---|---|---|---|
| Age 2–6 | Age 7–18 | |||||
| % | COR (95% CI) | AOR (95% CI) | % | COR (95% CI) | AOR (95% CI) | |
| Infection | 4.6% | Reference | Reference | 1.3% | Reference | Reference |
| Infection and OSA | 18.2% | 4.61 (1.01–21.23) | 4.82 (1.09–21.48) | 6.5% | 4.88 (0.92–30.08) | 4.38 (0.81–27.47) |
| Infection and SDB | 4.1% | 0.88 (0.20–3.84) | 0.83 (0.20–3.39) | 2.6% | 1.89 (0.36–11.48) | 1.70 (0.32–10.34) |
| OSA | 5.1% | 1.11 (0.42–3.81) | 0.63 (0.23–2.09) | 3.2% | 2.09 (0.60–10.93) | 2.26 (0.57–12.66) |
| SDB | 4.6% | 1.01 (0.38–3.51) | 0.80 (0.30–2.64) | 0.0% | 0.18 (0.001–2.19) | 0.17 (0.001–2.09) |
| Uncontrolled pain* | ||||||
|---|---|---|---|---|---|---|
| Age 2–6 | Age 7–18 | |||||
| % | COR (95% CI) | AOR (95% CI) | % | COR (95% CI) | AOR (95% CI) | |
| Infection | 2.3% | Reference | Reference | 4.6% | Reference | Reference |
| Infection and OSA | 0.0% | 0.76 (0.01–9.78) | 0.57 (0.004–7.59) | 4.3% | 1.10 (0.20–4.29) | 0.64 (0.11–2.75) |
| Infection and SDB | 0.0% | 0.17 (0.001–2.17) | 0.18 (0.001–2.19) | 1.7% | 0.43 (0.08–1.65) | 0.40 (0.07–1.55) |
| OSA | 0.9% | 0.34 (0.08–1.94) | 0.23 (0.04–1.43) | 1.6% | 0.35 (0.11–1.06) | 0.21 (0.06–0.78) |
| SDB | 0.8% | 0.31 (0.07–1.82) | 0.29 (0.06–1.71) | 1.2% | 0.29 (0.05–1.10) | 0.31 (0.05–1.24) |
Note: Bold values indicate statiscally significant.
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; OSA, obstructive sleep apnea; SDB, sleep disordered breathing.
For ages 2–6, uncontrolled pain was defined as having an emergency department visit for uncontrolled pain, while among ages 7–18 it also included oxycodone refill.
4. Discussion
Tonsillectomy is one of the most common pediatric procedures; however, it is plagued by pain control, dehydration, and bleeding risks which burden families, physicians, and the healthcare system [6, 7, 8]. The prevention of these late complications can reduce not only stress on families but added healthcare costs as well. While intraoperative dexamethasone is routinely utilized to reduce nausea/vomiting and improve recovery, the role of outpatient oral steroid prescription in post‐tonsillectomy care is still being elucidated. Glucocorticoids like dexamethasone can have an anti‐inflammatory effect by suppressing the migration of neutrophils and decreasing lymphocyte colony proliferation [21]. Since Papangelou et al. proposed postoperative oral steroid as a useful adjunct medication for post‐tonsillectomy recovery [14], there have been few studies analyzing its effects, which often are limited by low patient volume, mixture of adult and pediatric patients, and heterogeneous steroid types and dosing regimens within the same study. Further, results have been conflicting with some demonstrating no significant difference in pain, nausea/vomiting or diet based on subjective questionnaires, and others demonstrating significant improvement in these measures [5, 11, 16, 22]. Our study did not find significant associations of receiving postoperative steroids with bleeding, dehydration, or uncontrolled pain.
Recognizing the need for a prospective, randomized controlled trial with a standardized dosing regimen and both subjective and objective outcome measurements, Park et al. designed a study that demonstrated a significant improvement in pain, diet, activity, mean area of re‐epithelialization, fever, and sleep disturbance by post‐operative day 7 in pediatric patients receiving prednisolone [18]. Furthermore, the study performed a sub‐analysis on tonsillectomy indication, finding benefits of steroid in both infectious and non‐infectious indications with particular improvement in pain, diet, and activity in the non‐infectious group. However, this study was limited by low patient volume, a mixture of pediatric and adult patients, and only one pediatric patient with infectious indications receiving prednisolone [18].
Subsequently, Redmann et al. in a retrospective review of 1200 pediatric patients found that steroids were associated with significantly reduced parental phone calls and bleed rates, with no significant association with emergency department visits [19]. Our study is the largest on this topic and is specific to the pediatric population with a standardized weight‐based steroid dosing regimen using only monopolar electrocautery technique. Like Redmann et al. [19], our results are centered on outcomes requiring physician intervention, as this is objective measurable data that affects both physician, patient, and healthcare system. However, postoperative telephone encounters for pain were not analyzed in this study due to inconsistent EMR documentation. We therefore focused on reliably documented outcomes, including ED visits and pain medication refills, although less severe pain concerns managed through telephone communication may have been missed. Our study uniquely includes analysis of dehydration as a complication and controls for infectious indication.
Bleeding was the most common measured complication at 5.0%, a rate similarly seen in larger studies [23]. While prior studies on intraoperative dexamethasone yielded concern for increased bleeding in the post‐tonsillectomy population, subsequent studies refuted this. Indeed, even studies specific to postoperative oral steroid practices have generally shown either no difference or a statistically significant decrease in bleed rates. Our study did not find a significant association between postoperative steroids and bleeding, which follows along the conclusions of other papers who found no association in prescribing post‐operative dexamethasone, which may have not reached significance due to relatively low percentage of patients receiving steroids (30.4%) and relatively more stringent criteria to include bleeding as a complication (i.e., minor bleeding events captured by other studies likely not captured by ours as they did not prompt ED visits) [9, 19, 22, 24].
Dehydration and pain were less frequently recorded by patients compared to bleeding, likely because they are often not severe enough to prompt a return to the emergency department. Of note, dehydration was also significantly more common in younger patients (Figure 1). Pain was more common in older age children in line with prior studies, but also because uncontrolled pain among 7–18‐year‐olds covered both emergency department visits for pain and if the patient received an oxycodone refill, which was primarily prescribed to patients older than 6 years of age [25, 26]. Although instrumentation was standardized to monopolar electrocautery, power settings were not standardized and typically ranged from 15 to 16 W for tonsillar dissection and up to 20–24 W for hemostasis. Given the association between higher electrocautery power settings and increased postoperative pain, variation in cautery settings may represent a source of residual confounding in our pain‐related findings [27].
The novelty approach that we took to this study was controlling for tonsillectomy indication in the association of steroids with complication rates. Among ages 7–18, patients with OSA as their only indication for tonsillectomy had significantly lower odds of uncontrolled pain compared to patients with infection as their only indication. It is not fully understood as to why patients with infectious indications may experience more pain than non‐infectious indications. Studies have shown that one dose of intraoperative steroids was associated with significantly decreased pain scores in pediatric post‐tonsillectomy patients, but there is only one recent study that found a post‐operative steroid regimen was associated with decreased pain in pediatric post‐tonsillectomy patients overall [9, 28]. One possible reason for this is that patients with infectious indications are at risk of increased scarring from prior episodes of tonsillitis, and therefore altered tissue planes during dissection may lead to increased postoperative pain. There is one study that found that patients who underwent tonsillectomy for an infectious indication had higher pain scores and took painkillers for longer than patients with non‐infectious indications [20]. In the wake of the current opioid crisis, there is an increased need for reduced prescribing practices of pain medications such as oxycodone. More investigation needs to be undertaken to truly see if steroids can reduce uncontrolled pain, as this could serve to be a particularly useful alternative in reducing pain rates for pediatric patients undergoing a tonsillectomy. There were no recorded complications seen related to side effects of steroid prescription within 30 days after surgery, and it did not increase complications, so even if a significant difference was not seen in this study, a prospective randomized controlled trial could be safe to implement.
5. Conclusion
Among pediatric tonsillectomy patients, postoperative steroids were not significantly associated with bleeding, dehydration, or uncontrolled pain. However, because complications from steroids are extremely rare, using postoperative steroids as an adjunct prevention method for tonsillectomy complications may be reasonable. A larger prospective randomized trial is needed to investigate potential effects of post‐operative dexamethasone in post‐tonsillectomy patients.
Funding
This work is supported by a grant from the Saint Louis University Research Institute and resources from the AHEAD Institute.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
This work is supported by a grant from the Saint Louis University Research Institute and resources from the AHEAD Institute. Artificial intelligence tools were not used in the preparation of this manuscript.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.