Hemorrhage Rates in Pediatric Patients Receiving Postoperative Steroids After Tonsillectomy

ObjectiveTo investigate the impact of the surgical indication on posttonsillectomy bleed rates.Data SourcesPubMed, Scopus, CINAHL.Review MethodsA systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta‐analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.ResultsA total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep‐disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).ConclusionPatients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

Section: Resultsmentioning

confidence: 99%

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta‐Analysis

Gutiérrez

Shannon

Nguyen

et al. 2023

“…Corticosteroids present one mechanism that clinicians can leverage to reduce postoperative pain by reducing inflammation and edema 55 . While several studies demonstrated perioperative steroids' safety and efficacy, most are limited to pediatric populations 44‐54 . One meta‐analysis by Diakos et al concluded that dexamethasone reduced postoperative pain, nausea, vomiting, bleeding, and overall complications in adults undergoing tonsillectomy 57 .…”

Section: Discussionmentioning

confidence: 99%

“…For instance, the addition of corticosteroids to postoperative regimens improved pain scores, oral intake, and postoperative nausea and vomiting in pediatric patients undergoing tonsillectomy or adenotonsillectomy. [45][46][47][48][49][50][51][52][53][54][55] However, similar evidence of improved postoperative recovery and effects on postoperative opioid consumption is yet to be conclusively elucidated in adults.…”

Section: Discussionmentioning

confidence: 99%

“…55 While several studies demonstrated perioperative steroids' safety and efficacy, most are limited to pediatric populations. [44][45][46][47][48][49][50][51][52][53][54] One meta-analysis by Diakos et al concluded that dexamethasone reduced postoperative pain, nausea, vomiting, bleeding, and overall complications in adults undergoing tonsillectomy. 57 Most studies included in this meta-analysis utilized intraoperative dexamethasone without a postoperative course.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Prednisone Decreases Opioid Use in Adults Undergoing Benign Oropharyngeal Surgery

Butkus,

Sagalow,

Alfonsi

et al. 2023

ObjectiveThis study sought to analyze the efficacy and safety of postoperative prednisone to reduce reliance on opioids in adult benign oropharyngeal surgery.Study DesignProspective cohort study.SettingSingle tertiary‐care facility.MethodsPatients undergoing tonsillectomy (T), tonsillectomy and adenoidectomy (T&A), and/or modified uvulopalatopharyngoplasty (UPPP) from December 2020 to January 2023 received the standard of care postoperative management. A prednisone taper was dependent on surgeon preference. Cohorts were based on the prescription of postoperative steroids. Patients completed a survey to assess opioid usage, pain scores, and steroid compliance.ResultsSeventy‐two patients were included. The nonsteroid cohort (N = 29) received an average of 467 ± 94.1 morphine milligram equivalents (MME), and the steroid cohort (N = 43) received an average of 285 ± 128 MME (P < 0.001). The nonsteroid cohort consumed 1.62 times more opioids than the steroid cohort (P < 0.002). There were no significant differences in complication or refill rates between treatment groups. There were no significant differences in pain scores on the day of surgery or postoperative days 1, 5, or 10 (P = 0.34, P = 0.66, P = 0.62, and P = 0.22, respectively). Patients undergoing T&A (p = 0.019) or who had current psychiatric medication use (P < 0.006) consumed significantly more opioids. Patients who received a total opioid prescription of >300 MME (40 5‐mL doses of 5 mg/5 mL liquid oxycodone) consumed 2.27 times more postoperative opioids than patients with opioid prescriptions ≤300 MME (P < 0.001).ConclusionPatients who did not receive steroids consumed 1.62 times more postoperative opioids compared to those who completed a steroid taper. Corticosteroid use was not associated with changes in pain scores, refill rates, or complication rates and may be considered in a multimodal approach to pain management in adults undergoing benign oropharyngeal surgery, although further study is warranted.

Perioperative Use of Systemic Steroids Within Otolaryngology–Head and Neck Surgery: Evidence‐Based Guidance for Clinicians

Ikeda,

Gray,

Lee

et al. 2024

ObjectiveTo review and synthesize the available evidence for use of perioperative systemic steroids for otolaryngologic surgical procedures.Data SourcesA comprehensive literature review with evidence‐informed recommendations.Review MethodsDatabases were queried for medical subject heading terms and keywords related to perioperative systemic corticosteroids use for comprehensive otolaryngology and subspecialty procedures including otologic, sinonasal, sleep, laryngeal, head and neck, facial plastics, and pediatric surgery. Perioperative period included preoperative (up to 7 days prior to surgery), intraoperative (on the day of surgery), and postoperative (initiated within 24 hours after surgery) timeframes.ConclusionsEvidence from clinical practice guidelines, systematic reviews, and original research studies supports perioperative systemic corticosteroid use for specific otolaryngologic indications. Numerous studies support perioperative steroid use for nausea, vomiting, or edema in tonsillectomy, rhinoplasty, and thyroidectomy, although formal guideline recommendations are limited. Strong evidence supports perioperative steroid use before and after endoscopic sinus surgery for chronic rhinosinusitis with polyposis and fungal sinusitis. Evidence of benefit is sparse or absent on systemic perioperative steroid use for the middle and inner ear, laryngeal, salivary gland surgery, and reconstructive facial plastic surgery.Implications for PracticeAlthough perioperative administration of systemic steroids is routinely performed for many otolaryngologic surgeries, high‐level evidence is limited to specific contexts. Evidence supports the benefit for reducing nausea, vomiting, or edema for several otolaryngologic procedures, as well as for either chronic rhinosinusitis with polyposis or fungal sinusitis. However, these benefits need to be weighed against risks, and further investigations are needed to define the role for perioperative steroids in otolaryngology.