A short course of oral dexamethasone was associated with a modest reduction in pain after pediatric adenotonsillectomy, a placebo-controlled, quadruple-blind randomized controlled trial involving 209 children found.

There was no increase in complications in the intervention arm, and while intergroup differences fell below clinically meaningful levels, opioid prescriptions and emergency department (ED) visits for pain were much less common in dexamethasone recipients, according to investigators led by Amber D. Shaffer, PhD, clinical researcher in the Division of Pediatric Otolaryngology at the University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pennsylvania, writing in JAMA Otolaryngology–Head & Neck Surgery.

These results support the addition of this adjunct oral medication to postoperative regimens after this painful procedure. Poorly controlled postoperative pain can lead to dehydration, bleeding, and nausea, the authors noted.

“Tonsillectomy is common and painful, with 500,000 pediatric cases annually in the United States and about 2500 at our hospital,” Shaffer told Medscape Medical News. Pain often peaks on postoperative day 6 but can last beyond day 14, with intensity exceeding that reported after kidney transplantation or hysterectomy, she added. “Despite scheduled acetaminophen and ibuprofen, at least 10% of children require opioids, with 5% developing persistent opioid use.”

While randomized controlled trials have demonstrated that a single pre- or intraoperative dose of intravenous dexamethasone improves postoperative pain, nausea, and dietary tolerance , the efficacy of postoperative oral steroids is still under question.

Study Details

The trial enrolled patients aged 3-17 years (3-7 years, 56.5%; median age, 7.1 years). Around 53% were boys, and 86.6% were White. Enrollment of patients occurred from August 2021 to May 2023, with 14 days of follow-up for pain and 5-9 weeks for adverse events.

Oral dexamethasone (n = 104) at 0.5 mg/kg (max 20 mg) or placebo (n = 105) was given on postoperative days 2, 4, and 6.

Benefits on postoperative days 12-14 suggested that reducing inflammation early in the postoperative course may contribute to a smoother recovery as eschar sloughs off.

Mean pain before administration of acetaminophen or ibuprofen on days 2-8 was 0.72 points lower in the dexamethasone group than in the placebo group: 4.12 vs 4.84, but 95% CIs were admittedly wide. The dexamethasone group had less pre- and post-analgesic pain on postoperative days 12 and 13 (mean difference, 0.96-2.37 points) as well as a considerable decrease in the odds of receiving an opioid prescription: odds ratio (OR) of 0.23 (95% CI, 0.06-0.84); or visiting the ED for pain: OR of 0.12 (95% CI, 0.003-0.91).

In addition, older children experienced more postoperative pain regardless of the study arm, while dexamethasone had a greater impact in children aged 8-12 years than in those aged 3-7 years and 13-17 years.

Intergroup differences in readmissions, nursing telephone calls, post-tonsillectomy hemorrhage, and return to normal diet between groups were small and clinically insignificant.

Shaffer cautioned that the study did not measure compliance with dexamethasone and placebo. “Compliance should be measured in future studies to allow for per-protocol analyses and determine the effect when all 3 doses are taken as prescribed,” she said.

Oral dexamethasone is an inexpensive medication that may be a useful adjunct in post-adenotonsillectomy pain regimens. Although reductions in patient- and parent-reported pain may be relatively small, the benefits seem to be enough to avoid ED visits and requests for opioid prescriptions, said Shaffer.

Some pediatric ear, nose, and throat physicians are already following this postoperative steroid treatment. “I do use this approach in my practice,” Jordyn P. Siegel, MD, assistant professor in the Department of Otolaryngology at Eastern Virginia Medical School in Norfolk, who was not involved in the study, told Medscape Medical News.

Landon J. Duyka, MD, told Medscape Medical News, however, that not all pediatric patients need oral steroids after a tonsillectomy because pain can usually be managed with acetaminophen and ibuprofen or a short course of a low-dose opioid. “If, however, pain is not well-controlled with that regimen, a short course of oral steroids can be helpful. The safety and efficacy of this approach are demonstrated by this article,” said Duyka, the medical director of otolaryngology–head and neck surgery at Northwestern Medicine Catherine Gratz Griffin Lake Forest Hospital in Lake Forest, Illinois.

Duyka added that in his practice, adult patients are often sent home with an oral steroid taper lasting about a week “to aid in pain management since adults generally require higher doses and a longer course of pain medication after a tonsillectomy.”

Shaffer noted that the indication for adenotonsillectomy in children shifts from predominantly sleep-disordered breathing at 3-7 years of age to an equal distribution between sleep-disordered breathing and recurrent tonsillitis at 13-17 years of age, “so future studies are required to provide clarity on the positive correlation between age and pain scores and differential impacts of steroids.”

Investigational product and participant compensation were funded by the University of Pittsburgh Medical Center Children’s Hospital Foundation. The REDCap database was supported by a National Institutes of Health grant to the Clinical and Translational Sciences Institute at the University of Pittsburgh. Shaffer and co-authors, Siegel, and Duyka reported having no relevant conflicts of interest.