Intravenous dexamethasone is routinely given during tonsillectomy for its effects on postoperative pain and nausea. This Chinese randomised study divided 240 children undergoing tonsillectomy into three groups, receiving either no steroid, intravenous dexamethasone, or the same amount of dexamethasone infiltrated into the upper, middle and lower poles of the tonsils. The same volume of saline was infiltrated into the tonsils in the first two groups as a control, and to maintain surgeon blinding.
The authors found that postoperative pain scores were significantly affected by the technique used: the highest pain scores in the non-steroid group, significantly lower in the IV steroid group, and significantly lower again in the local infiltration group. These children also had lower opiate (fentanyl) requirements postoperatively. However, postoperative nausea and vomiting was lower in the IV group than the local group, presumably due to lower systemic absorption. Readmission rates for vomiting or pain control were not affected.
Local infiltration of steroid is not common UK practice, although local anaesthetic infiltration is used in some centres. This well-conducted study demonstrates a useful adjunctive measure in tonsillectomy symptom control. The authors intended, but were unable to, perform blood assays of steroid concentration in the study participants. Presumably, a future study including these measurements might lead to development of a dual IV+local steroid protocol, with appropriate safe dosing, thus improving postoperative pain whilst eliminating the need for compromise of nausea prevention.
